SOCIAL
PROTECTION in HEALTH SCHEMES
for MOTHER, NEWBORN
and CHILD POPULATIONS:
Lessons Learned from the Latin American Region
Social Protection in Health Schemes
for Mother, Newborn
and Child Populations:
LESSONS LEARNED FROM THE LATIN AMERICAN REGION
Washington DC,
June, 2008
PAHO HQ Library Cataloguing-in-Publication
Pan American Health Organization. Area of Health Systems Strengthening. Health
Policies and Systems Unit.
Social protection in health schemes for mother and child population: lessons
learned from the Latin
American Region.
Washington, D.C.: PAHO, © 2007.
ISBN 978 92 75 12841 1
I. Title
1. SOCIAL SECURITY
2. MATERNAL AND CHILD HEALTH
3. FAMILY HEALTH PROGRAM
4. LATIN AMERICA
NLM HD 4826
This publication was produced by the Health Policies and Systems Unit, Health Systems Strengthening Area
(HSS/HP) of the Pan American Health Organization/World Health Organization (PAHO/WHO). This publication
was made possible through support provided by the Office of Regional Sustainable Development, Bureau for
Latin America and the Caribbean, U.S. Agency for International Development (USAID), under the terms of
Grant No. LAC-G-00-04-00002-00; the Swedish International Development Cooperation Agency (SIDA), under
the terms of Grant No. 163122 and the Spanish International Cooperation Agency (AECI), under the terms of
Grant No. XI PAC OPS-AECI-MSC-ISC III.
The opinions expressed in this publication are those of the author (s) and do not necessarily reflect the views
of the USAID, SIDA nor AECI.
The electronic version of this document is available at the Web site for Health Systems Strengthening in Latin
America and the Caribbean and can be accessed at www.lachealthsys.org. For any questions or inquiries regarding this document, please contact acunamar@paho.org.
© Pan American Health Organization, 2007
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Cover Design and Layout: María Laura Reos / OPS/OMS
Cover Photo by Danilo Vitoriano
“The primary determinants of disease are mainly
economic and social, and therefore
its remedies must also be economic and social.
Medicine and politics cannot and should not be
kept apart”.
Geoffrey Rose
“The strategy of preventive medicine”, 1992.
“Health is the result of fair socio-economic
development”
Sergio Arouca, 2003
PRESENTATION
Due to the wide variety of interventions in place, the task of identifying and
describing social protection in health schemes (SPHS) for mother, newborn and
child populations in the Latin American and Caribbean (LAC) region is an arduous one. While nearly all Latin American countries have implemented immunization and nutrition programs that are standardized according to a global
consensus based on worldwide experience on what works best, health protection
schemes aimed at guaranteeing access to health care to mothers and children
are heterogeneous and have achieved varying degrees of success. Along with
those factors within the health sector that hinder the timely delivery and quality of
health services, a number of conditions outside the health sector play a key role
in determining access to care and health outcomes in LAC countries. The political situation and social determinants of health are of paramount importance in
the performance of SPHS in the region, given the fact that political instability and
inequity shape the social landscape of many countries.
The availability of comprehensive reproductive and child health care remains
an unrealized goal in most of the world, and some countries have actually experienced stagnation or even reversals in their maternal and child health indicators (World Health Organization -WHO-, 2005). This reality has prompted
policymakers and international cooperation agencies to focus on the implementation of different mother, newborn and child health protection schemes in order
to improve access to care for these populations. Although the impact of many of
these interventions on health processes and outcomes is well-documented in the
LAC Region, further comparative analysis is needed to identify lessons learned
and to understand the role these interventions play in the broader institutional
setting of existing health systems and their relationship with social determinants
of health such as socio-economic status, gender, and ethnicity.
In the context of this need, the Pan American Health Organization (PAHO) has
partnered with three international cooperation agencies to study the best methods for redressing exclusion from health care among the maternal, newborn and
child population.
• PAHO and the Swedish International Development Agency (SIDA) have been
working together since 2000 to support the efforts of LAC countries to address social exclusion in health and to develop strategies to extend social
protection in health. PAHO/SIDA have focused on characterizing exclusion
from health care and increasing awareness of the problem through support
for social and policy dialogues between social and political actors. These
dialogues are aimed at implementing Plans of Action to reduce exclusion
and expand protection in health.
• The PAHO-USAID (United Satetes Agency for International Development)
three-year agreement, signed in June 2004, also places a strong emphasis
on maternal and neonatal health. This component of the agreement consists of two main activities:
1.
Identify, describe and document different models of and experiences
with SPHS in LAC as they relate to Maternal, Neonatal and Child Health
(MNCH).1
2.
Based on the different models/experiences identified, develop a comparative analysis of the strengths and weaknesses of different social health
protection schemes for mother, newborn and child populations.
• The third component of the 11th Joint Action Plan (PAC-XI), subscribed to
by PAHO/WHO and the Spanish International Cooperation Agency (AECI),
concentrates on developing actions that will extend social protection in
health to the mother, newborn and child population, in line with Millennium
Development Goals (MDGs) 4 and 5 (to reduce infant mortality and improve maternal health). PAHO and AECI seek to support countries in their
efforts to develop their institutional capacity to extend social protection in
health, with a focus on mothers, newborns, and children.
This analysis is the first step in a process aimed at increasing knowledge about
the dynamics of health access for mothers, newborns, and children. We hope
this effort will contribute to the goal of extending social protection in health to
these populations in the LAC Region.
Pedro Brito
Area Manager
Health Systems and Servicies
1.
Typically, most organizations, including WHO, refer to mother and child health as MCH. But in its 2005 World Health Report,
WHO specifically highlights the importance of tackling the health needs of newborns. Hence in this document we will use the
acronym MNCH which stands for maternal, neonatal, and child health.
ACKNOWLEDGMENT
This report is the product of a joint initiative between PAHO/WHO, USAID,
SIDA and AECI, initiated in 2004/05 to identify options for extending social
protection in health to mothers, newborns, and children in LAC. It relies
strongly on concepts and methodologies developed since 2000 by PAHO
and SIDA and on the conceptual developments of the ILO(Intenational Labour Organization)-PAHO Joint Initiative on Extension of Social Protection
in Health.
Two teams, one from the Health Policies and Systems Unit (HSS-HP) and
the other from the Women and Reproductive Health Unit (FCH-CLAP/WR)
and Child and Adolescent Unit (FCH-CA), within the Areas of Health Systems and Servicies and Family and Community Health, respectively, worked
together on the publication of this paper, under the supervision of Eduardo
Levcovitz and Gina Tambini.
Cecilia Acuña from HSS-HP led the research team and was responsible for
the development of the report. The research team also consisted of:
•
•
•
•
•
•
Virginia Camacho, FCH-CLAP/WR
Andrew Griffin, HSS-HP
Rafael Obregon, FCH-CA
Jessica Rada, Intern, HSS-HP
Caroline Ramagem, HSS-HP
Sarah Watson, Intern, HSS-HP
Soledad Urrutia from HSS-HP and Rachel Kauffmann from FCH-WR provided important support to the information gathering process. Cristine Sulek
from HSS-HP provided administrative support.
We would like to thank the valuable inputs made by the participants in the
experts’ meeting held in Buenos Aires, Argentina, in August 2005, where a
preliminary version of this report was presented. Also, we deeply appreciate the comments made by the participants in the Regional Forum “Social
protection in health for women, newborn, and child populations in LAC:
lessons learned to prompt the way forward” held in Tegucigalpa, Honduras
in November 2006, where the report served as background paper. Last but
not least, we are grateful of the helpful contributions made by our counterparts from USAID, Kelly Saldaña and Peg Marshall. All of them helped to
improve this report; its shortcomings remain ours alone.
LIST OF ACRONYMS
AECI:
Agencia Española de Cooperación Internacional
ARI:
Acute Respiratory Infections
AUGE:
Acceso Universal con Garantías Explícitas
(Spanish International Cooperation Agency)
(Universal Access with Explicit Guarantees)
BE:
Bono Escolar (School Voucher)
BMI:
Bono Materno Infantil
(Mother and Child Voucher)
CDC:
Centers for Disease Control and Prevention
CONAMU:
Consejo Nacional de las Mujeres
(National Women Council)
CSDH:
Commission on Social Determinants of Health
DHS:
Demographic and Health Survey
DILOS:
Directorio Local de Salud
(Local Health Directory)
ECLAC:
Economic Commission for Latin America and the Caribbean
ENDSA:
Encuesta Nacional de Demografía y Salud
ESSALUD:
Seguro Social de Salud de Perú
FONASA:
Fondo Nacional de Salud
FONNIN:
Fondo Nacional de Nutrición Infantil
(National Demographic and Health Survey-DHS)
(Peru’s Social Security Institute)
(National Health Fund)
(National Fund for Nutrition)
GDI:
Gross Domestic Income
GDP:
Gross Domestic Product
GNI:
Gross National Income
GRADE:
Grupo de Análisis para el Desarrollo
(Analysis for Development Group)
HIPC:
Heavily Indebted Poor Countries
IBGE:
Instituto Brasileiro de Geografia e Estatística
IDB:
Inter-American Development Bank
ICU:
Intensive Care Units
IESS:
Instituto Ecuatoriano de Seguridad Social
(Brazilian Institute of Geography and Statistics)
(IADB)
(Ecuadorian Social Security Institute)
IHSS:
Instituto Hondureño de Seguridad Social
(Honduran Social Security Institute)
ILO:
International Labour Organization
IMCI:
Integrated Management of Childhood Illness
(OIT)
IMR:
Infant Mortality Rate
IMSS:
Instituto Mexicano del Seguro Social
INEC:
Instituto Nacional de Estadísticas y Censos de Ecuador
INEI:
Instituto Nacional de Estadística e Informática
ISAPRE:
Instituciones de Salud Previsional
ISSSTE:
Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado
LAC:
Latin America and the Caribbean
(Mexican Social Security Institute)
(Ecuador National Institute of Statistics and Censuses)
(National Institute of Statistics and Information Technology)
(Private Health Insurance Funds)
(Institute of Social Security and Services for State Workers)
LACHSR:
Latin America and the Caribbean Regional Health Sector Reform Initiative
LMGYAI:
Ley de Maternidad Gratuita y Atención a la Infancia
(Free Maternity and Child Care Law)
MCH:
Mother and Child Health
MNCH:
Mother, Newborn and Child health
MCHSHPP:
Mother and Child Social Health Protection Policy
MINSAL:
Ministerio de Salud de Chile
(Chilean Ministry of Health)
MMR:
Maternal Mortality Ratio
MDG’s:
Millennium Development Goals
MIDEPLAN:
Ministerio de Planificación y Cooperación de Chile
(Chilean Ministry of Planning and Cooperation)
MSP:
Ministerio de Salud Publica
(Ministry of Health)
OECD:
Organization for Economic Cooperation and Development
PACS:
Programa de Agentes Comunitários de Saúde
PAE:
Programa de Alimentación Escolar
(Community Health Agents Program)
(School Feeding Program)
PAHO:
Pan American Health Organization
PEN:
Peruvian Nuevo Sol
PNAC:
Programa Nacional de Alimentación Complementaria
(OPS)
(National Complementary Feeding Program)
PPP:
Purchasing Power Parity
PRAF:
Programa de Asignación Familiar
PROGRESA:
Programa de Educación, Salud y Alimentación
PSF:
Programa Saúde da Família (Brazil)
PSF:
Plan de Salud Familiar (Chile)
SAP:
Structural Adjustment Programs
SBS:
Seguro Básico de Salud
(Family Allowance Program)
(Education, Health and Nutrition Program)
(Family Health Program)
(Family Health Plan)
(Basic Health Insurance)
SEG:
Seguro Escolar Gratuito
(Free School Insurance)
SPHS:
Social Protection in Health Scheme
SIDA:
Swedish International Development Agency
SIS:
Seguro Integral de Salud
SMI:
Seguro Materno Infantil
SNMN:
Seguro Nacional de Maternidad y Niñez
SUMI:
Seguro Universal Materno Infantil
SUS:
Sistema Único de Saúde
TGN:
Tesoro General de la Nación
UN:
United Nation
(ASDI)
(Integrated Health Insurance)
(Mother and Child Insurance)
(National Mother and Child Insurance)
(Universal Mother & Child Insurance)
(Unified Health System)
(National General Treasury)
(ONU)
UNDP:
United Nations Development Fund
UNFPA:
United Nations Fund for Population Activities
UNICEF:
United Nations Children’s Fund
USAID:
United States Agency for International Development
WB:
World Bank
WHO:
World Health Organization
(BM)
(OMS)
CONTENTS
Executive Summary
-1-
1. Introduction
-5-
2. Background
-11-
3. Conceptual Framework
3.1) Description of the Social Protection in Health Schemes (SPHS)
currently in place in the region
3.2) Analysis of the strengths and weaknesses of the SPHS
-19-19-27-
4. Analytical Framework
4.1) Objectives
4.2) Methods
4.3) Conducting the Analysis
4.4) Information Sources
4.5) Limitations of the analysis
-42-42-43-48-49-50-
5. Case Studies
5.1) Universal Mother & Child Insurance (Bolivia)
5.2) The Family Health Program (Brazil)
5.3) Mother & Child Social Health Protection Policy (Chile)
5.4) Free Maternity and Child Care Law (Ecuador)
5.5) Mother and Child Voucher (Honduras)
5.6) OPORTUNIDADES Program (Mexico)
5.7) Integrated Health Insurance (Peru)
-51-51-62-72-82-96-107-118-
6. Results
-131-
7. Discussion and Lessons Learned
-137-
References
-149-
EXECUTIVE SUMMARY
In the context of current PAHO/WHO agreements with USAID, SIDA, and
AECI, research was carried out to gather information on social protection in
health schemes (SPHS) aimed at mothers, newborns, and children in the Latin
American (LA) Region. In order to do so, a cross-sectional descriptive analysis
based on a literature/internet review and secondary sources was carried out.
For the purposes of this study, SPHS were defined as public interventions directed at allowing groups and individuals to meet their health needs and
demands through access to health care goods and services in adequate conditions of quality, opportunity, and dignity, regardless of their ability to pay.1
The information gathered during the research process served as the knowledge base for a comparative analysis with two objectives:
a) Identify, describe, and document different models of/experiences with
SPHS in LA as they relate to Maternal, Neonatal, and Child Health
(MNCH);
b) Based on the different models/experiences identified, develop a comparative analysis of the strengths and weaknesses of different SPHS
for mother, newborn, and child populations in terms of their ability to
expand coverage of health services, increase equity in the access to
care and offset social determinants that negatively effect health status
and/or the demand for health care.
a) Description of SPHS currently in place in the region
A typology of SPHS was developed based on the work of the Organization for
Economic Cooperation and Development (OECD) Development Centre and
OECD Health Project (Drechsler D., Johannes J., 2005; Colombo F., Tapay
N., 2004) as well as on Wouter van Ginneken’s and Bonilla and Gruat’s work
for ILO (Van Ginneken, 1996; Bonilla and Gruat, 2003) and on our own
observations.
1.
This definition is derived from the PAHO-WHO Resolution CSP26.R.19 of September 2002, which defines Extension of
Social Protection in Health -ESPH as the “society’s guarantee, through the different public authorities, that individuals or
groups of individuals can meet their needs and demands in health through adequate access to the services of the system or to
those of any of the existing health subsystems in the country, regardless of their ability to pay.”
1
b) Analysis of strengths and weaknesses
A multi-country cross sectional analysis based on literature/internet review and secondary sources was conducted. We based our analysis of
strengths and weaknesses on four principles, selected both for their welldocumented importance on MNCH and because they serve as points of
consensus among experts in maternal, newborn, and child health (WHO,
2005; United Nations -UN- Millennium Development Project, 2005; Interagency Strategic Consensus for Latin America and the Caribbean,
2003). The following principles were selected:
I. Equity is central to MNCH;
II. MNCH is strongly linked to larger social determinants of health;
III. Improving coverage of and access to technically appropriate
interventions is crucial to achieving better outcomes in MNCH;
IV. Context matters in the performance of SPHS. Any analysis of
SPHS must be rooted in their social, political, and economic
context.
According to these principles, three performance parameters were defined:
i.
The ability of the SPHS to increase equity in the access to care
and/or in the utilization of health services;
ii. The extent to which the SPHS contributes to offsetting social
determinants that affect health status and/or hinder the demand
for health care - i.e. the role the SPHS plays in shaping the
social environment in ways that contribute to better health;
iii. The ability of the SPHS to expand coverage of and increase
access to technically appropriate health interventions by
eliminating one or more causes of exclusion from health care.
Seven SPHS were selected and characterized using this framework: Bolivia’s Mother and Child Universal Insurance (Seguro Universal Materno
Infantil, SUMI), Brazil’s Family Health Program (Programa Saúde da
Família, PSF), Chile’s Mother and Child Social Health Protection Policy
(MCHSHPP), Ecuador’s Free Maternity Law (Ley de Maternidad Gratuita y
Atención a la Infancia, LMGYAI), Honduras’s Mother and Child Voucher
(Bono Materno-Infantil, BMI), Mexico’s OPORTUNIDADES Program and
Peru’s Integrated Health Insurance (Seguro Integral de Salud, SIS).
2
The selection was based on the availability of reliable information and
the scheme’s importance in the country, as measured by the resources
allocated to it as well as its priority on the public agenda. The strengths
and weaknesses of the selected SPHS were analyzed according to the
schemes’ compliance with the three performance parameters established
above.
Additionally, acknowledging the importance of social and political context on the performance of health interventions (Commission on Social
Determinants of Health- CSDH 2005, UN Millennium Development Project, 2005), the general setting in which each SPHS operates was also examined. The elements used to describe the general situation included the
country’s poverty level, per capita income, education level, percentage
of population living in rural dwellings or remote settlements, population’s
ethnic background, access to water/sanitation/electricity, and employment condition (level of unemployment and share of formal vs. informal
workers). Where information was available, women’s status, institutional
strength, distribution of power, and governance were also included in the
analysis.2
Our main findings from the analysis of the seven SPHS were the following:
a)
Four of the seven schemes under analysis - Bolivia’s SUMI,
Brazil’s PSF, Chile’s MCHSHPP, and Mexico’s OPORTUNIDADES - have
increased equity in the access to and/or utilization of health services.
Three schemes, Ecuador’s LMGYAI, Honduras’s BMI, and Peru’s SIS,
show mixed results, and, in some cases, have increased inequity in the
access to and/or utilization of health services.
b)
All of the schemes under consideration helped to offset at least
one of the negative social determinants of health, most frequently poverty, but only four of the analyzed schemes - Bolivia’s SUMI, Brazil’s PSF,
Chile’s MCHSHPP, and Mexico’s OPORTUNIDADES - had a clear and
unambiguous effect. The amount of investment in the program, the degree of coverage, continuity over time, the improvement of women’s social status within the family, and the explicit promotion of the right to
2.
For the purposes of the analysis we adopted the United Nations Development Fund (UNDP) definition of governance (UNDP,
1997) as “the exercise of political, economic and administrative authority in the management of a country’s affairs at all
levels”. The definition comprises the complex mechanisms, processes, relationships, and institutions through which citizens and
groups articulate their interests, exercise their rights and obligations and mediate their differences.
3
health appear to be crucial factors in the ability of the SPHS to tackle
negative social determinants.
c)
All seven schemes under analysis contributed to reducing the
impact of at least one cause of exclusion from health care. Most of the
schemes removed economic barriers to health care. However, the analysis of Bolivia’s SUMI, Honduras’s BMI and Peru’s SIS shows that in ethnically diverse countries and/or countries with geographically dispersed
human settlements, removing economic barriers alone does not guarantee access to health care.
d)
Only two schemes - Brazil’s PSF and Chile’s MCHSHPP - have
increased coverage of technically appropriate health interventions. Three
schemes - Bolivia’s SUMI, Ecuador’s LMGYAI and Peru’s SIS - have placed
additional constraints on the health system by increasing the demand for
health services without expanding provision, resources, and infrastructure
accordingly.
e)
Only in two cases - those of Chile’s MCHSHPP and Bolivia’s
SUMI - have schemes achieved more than 60% coverage of the eligible
population. Along with continuity over time and investments in resources and infrastructure, institutional capacity and decentralization of the
scheme’s management seem to play an important role in achieving the
expected coverage.
f)
Although not enough data has been collected regarding financial sustainability, three of the seven schemes - Bolivia’s SUMI, Ecuador’s
LMGYAI, and Honduras’s BMI - reportedly face financial shortages that
threaten their sustainability.
This report argues that the improvement of mother, newborn, and child
health can only be achieved through a holistic approach, combining
interventions that address social, economic, cultural, age related and
ethnic barriers to accessing health care. This multifaceted approach must
be based on a long-term societal and political agreement.
4
INTRODUCTION
1
INTRODUCTION
The health of mothers, newborns, and children is currently at the center
of the agendas of multilateral organizations, international cooperation
agencies, and governments around the world. This importance is mirrored in the MDGs (Millennium Development Goals), which express the
historic consensus of the international community as to which high-priority challenges must be faced to improve the quality of life of people
around the world and achieve sustainable development (PAHO/WHO,
2004). All eight MDGs are directly or indirectly related to health, particularly the health of mothers and children, as shown in table 1.
Table 1: Millennium Development Goals
Goals and targets
Indicators
Goal 1: Eradicate extreme poverty and hunger
Target 1: Halve, between 1990 and 2015,
the proportion of people whose income is
less than $1 a day
Target 2: Halve, between 1990 and 2015,
the proportion of people who suffer from
hunger
•
•
•
•
•
Proportion of population whose income is below $1
(PPP) a day
Poverty gap ratio (incidence x depth of poverty)
Share of poorest quintile in national consumption
Prevalence of underweight children (under five years of
age)
Proportion of the population below minimum level of
dietary energy consumption
Goal 2: Achieve universal primary education
Target 3: Ensure that, by 2015, children
everywhere, boys and girls alike, will be
able to complete a full course of primary
schooling
•
•
•
Net enrollment ratio in primary education
Proportion of pupils starting grade 1 who reach grade 5
Literacy rate of 15 to 24-year-olds
5
INTRODUCTION
Goal 3: Promote gender equality and empower women
•
Target 4: Eliminate gender disparity in
primary and secondary education preferably
by 2005 and in all levels of education no
later than 2015
•
•
•
Ratio of girls to boys in primary, secondary, and tertiary
education
Ratio of literate women to men ages 15 to 24
Share of women in wage employment in the nonagricultural sector
Proportion of seats held by women in national parliament
Goal 4: Reduce Child Mortality
Target 5: Reduce by two thirds, between
1990 and 2015, the under-five mortality
rate
•
•
•
Under-five mortality rate
Infant mortality rate
Proportion of one-year-old children immunized against
measles
•
•
Maternal mortality ratio
Proportion of births attended by skilled health personnel
Goal 5: Improve Maternal Health
Target 6: Reduce by three quarters, between
1990 and 2015, the maternal mortality
ratio
Goal 6: Combat HIV/AIDS, Malaria, and other diseases
Target 7: Have halted and begun to reverse
the spread of HIV/AIDS by 2015
Target 8: Have halted and begun to reverse
the incidence of malaria and other major
diseases by 2015
•
•
•
HIV/AIDS prevalence, both sexes
Contraceptive use rate
Ratio of school attendance of orphans to school attendance of non-orphans ages 10-14
•
•
Prevalence and death rates associated with malaria
Proportion of population in malaria-risk areas using
effective malaria prevention and treatment measures
Prevalence and death rates associated with tuberculosis
Proportion of tuberculosis cases detected and cured
under directly observed treatment short course (DOTS)
•
•
Goal 7: Ensure Environmental Sustainability
•
•
Target 9: Integrate the principles of sustainable development into country policies and
programs, and reverse the loss of environmental resources
•
•
•
Target 10: Halve, by 2015, the proportion
of people without sustainable access to safe
drinking water and basic sanitation
Target 11: Have achieved, by 2020, a significant improvement in the lives of at least
100 million slum dwellers
6
•
•
•
Proportion of land area covered by forests
Ratio of area protected to maintain biological diversity
to surface area
Energy use (kilograms of oil equivalent) per $1 GDP
(PPP)
Carbon dioxide emissions (per capita) and consumption of ozone-depleting chlorofluorocarbons (ODP
tons)
Proportion of population using solid fuels
Proportion of population with sustainable access to an
improved water source, urban and rural
Proportion of population with access to improved
sanitation, urban and rural
Proportion of households with access to secure tenure
INTRODUCTION
Goal 8: Develop a Global Partnership for Development
Target 12: Develop further an open, rule-based, predictable, nondiscriminatory trading and financial system
(includes a commitment to good governance, development, and poverty reduction – both nationally and
internationally)
Target 13: Address the special needs of the least developed countries (includes tariff-and quota-free access
for exports enhanced program of debt relief for HIPC (Heavily Indebted Poor Countries) and cancellation of
official bilateral debt, and more generous ODA for countries committed to poverty reduction)
Target 14: Address the special needs of landlocked countries and small island developing states (through the
Program of Action for the Sustainable Development of Small Island Developing States and 22nd General
Assembly provisions)
Target 15: Deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term
Target 16: In cooperation with developing countries, develop and implement strategies for decent and productive work for youth
Target 17: In cooperation with pharmaceutical companies, provide access to affordable, essential drugs in
developing countries
Target 18: In cooperation with the private sector, make the benefits of new technologies available, especially
information and communications
SOURCE: “The Millennium Development Goals: a Latin American and Caribbean perspective” ECLAC, 2005
In this context, maternal, neonatal and child health has ceased to be the
object of merely technical consideration and has become one ethical
and political imperative. This is due to the fact that despite impressive
advances made since the 1950s in the fight against maternal and child
mortality, inequality between countries and among different population
groups within countries - especially the gap between rich and poor - has
increased in the past twenty years, producing stagnation and, in some
cases, a relapse in the progress achieved in maternal and child health
(WHO, 2005). Moreover, three factors have negatively affected the patterns of maternal and child morbidity and mortality in the LAC Region:
(i) the economic crises of the 1980s and late 1990s, which resulted in
slow and volatile economic growth, high levels of inflation and unemployment and a decrease in the capacity of the public sector to provide
essential health services; (ii) the social crises produced by increasing
unemployment and informal economic activity, highly unequal income
distribution, and the reduced presence of the State in areas such as
education and health; and (iii) the HIV/AIDS pandemic (WHO, 2005;
Levcovitz E, Acuña C, 2003; Economic Commission for Latin America
and the Caribbean- ECLAC, 2005).
7
INTRODUCTION
Every year, around 23,000 women die of complications during pregnancy and childbirth in LAC. In twelve countries of the Region, the maternal
mortality ratio remains over 100 per 100,000 live births (PAHO/WHO,
2004). Most of these deaths are preventable (Regional Interagency
Task Force Strategic Consensus for the Reduction of Maternal Mortality,
2003). Two of the key determinants of high maternal mortality ratios are
the delay in access to health care when danger signs go unrecognized,
and the lack of access to prompt and quality attention by skilled personnel, both during childbirth and postpartum (PAHO/WHO-USAID, 2004).
Most of the women who die are poor, of indigenous origin, uneducated,
and from rural areas (PAHO/WHO, 2004; WHO, 2005). These deaths
have enormous social, economic, and emotional repercussions for families and communities, and are a determining factor in the generational
transmission of poverty.
In 2004, eleven countries in the Americas had an under-five mortality
rate of over 40 per 1,000 live births. As a whole, these countries are responsible for approximately 274,000 deaths of children under five years
old, which is equivalent to 60.6% of all the deaths for this age group
in LAC (PAHO/WHO-USAID, 2004 ECLAC, 2005). Meanwhile, eight
countries had under-five mortality rates of fewer than 20 per 1,000 live
births. This fact highlights the wide disparities prevailing among countries
in the region. Nevertheless, the national averages do not reflect the existing gaps within countries. Ethnicity, income level, and area of residence
seem to be the variables most strongly correlated with under-five mortality rate disparities within at least seven countries in the region - Bolivia,
Brazil, Colombia, Guatemala, Haiti, Peru, and the Dominican Republic.
In the region as a whole, however, access to sanitation and potable water, household income, and the mother’s education level remain the most
important determinants of under-five mortality. Lack of access to health
care is an increasingly important cause of infant and neonatal mortality
(PAHO/WHO-USAID, 2004; WHO, 2005).
Rising inequalities in the access to health care explain the stagnation
in maternal, neonatal, and infant mortality rates observed in a number
of LAC countries, despite of the existence of effective interventions to
prevent or to treat the main causes of maternal and child death (WHO,
2005). Exclusion in health - defined as the lack of access of some groups
or individuals to the health goods, services, and opportunities that other
members of society enjoy (PAHO/WHO, 2003) - remains a challenge
that requires urgent attention in most countries of the region.
8
INTRODUCTION
To address this situation, many governments, multilateral financial institutions, and international technical cooperation agencies have concentrated their efforts on promoting and implementing SPHS for mother,
newborn, and child populations. Their goal is to improve access to and
quality of MNCH interventions, in turn helping to reach the Millennium
Development Goals by the year 2015 (WHO, 2005).
PAHO/WHO has made supporting the countries in their efforts to eliminate exclusion in health, through the extension of social protection in
health, a priority for its technical cooperation efforts. Social protection
is here understood as the guarantee, granted by society through the
State, that an individual or group of individuals can meet its needs and
demands for health care through adequate and timely access to health
services, without the ability to pay, nor cultural, social, or personal attributes, serving as restrictive factors.3
In addition, the reduction of maternal, neonatal and child mortality is a
key component of PAHO/WHO’s agenda. Recognizing the importance
of this issue and its impact in the international context, Member States
approved three key resolutions during the 2002 Pan American Sanitary
Conference: Resolution CSP26.R.19, Resolution CSP26.R 13-14 and
Resolution CSP26.R 10. The first Resolution called for PAHO/WHO and
ILO to support and strengthen the extension of social protection in health
in Member States as part of their technical cooperation activities. The
second resolution urged Member States to make a full commitment to
reduce maternal mortality by approving a new regional strategy. And the
third Resolution encouraged Member States to support further implementation and strengthening of Integrated Management of Childhood
Illness (IMCI) activities in order to improve child health and reduce child
mortality in the region. Furthermore, in 2004 PAHO/WHO’s 45th Directive Council adopted Resolution CD45.R3, urging Members States to
strengthen their political commitment to the Millennium Declaration by
developing and implementing national plans to achieve the MDGs.
PAHO/WHO and AECI have agreed to work together to strengthen LAC
countries’ political, institutional, organizational, and human capacities
so that they can extend social protection in health and reduce inequities
in the access to health care, in the utilization and financing of health
3.
Op. Cit 1
9
INTRODUCTION
services, and in health outcomes (PAHO-AECI Agreement 2005-2007).
At the same time, since 1986, USAID and PAHO/WHO have worked
together in areas of common interest - among them health systems
strengthening and maternal and child health. Similarly, PAHO and SIDA
have been working together since 2000 to support the efforts of LAC
countries to address social exclusion in health and to develop strategies
to extend social protection in health.
Within this framework of cooperation, and eight years from the deadline
established for the achievement of the MDGs, it is important to examine
how the implementation of health protection schemes and other strategies to extend social protection in health has affected the health of
mothers and children. The purpose of this document is to analyze these
schemes comparatively, with the goal of understanding why certain strategies perform better than others in guaranteeing access to maternal,
neonatal, and child health services. Through this analysis we hope to
identify the best mechanisms for achieving universal social protection in
health for mothers, newborns, and children.
10
BACKGROUND
2
BACKGROUND
The protection of the health of mothers and children is not a new topic
in the public policy sphere. It has been a priority on the social agenda of
many countries since the nineteenth century, which in large part explains
the drastic reduction in maternal and child mortality seen around the
world during the 20th century. The creation of public health programs
to improve the health of women and children became a priority after the
Second World War, as seen in the 1948 Universal Declaration of Human
Rights, which stated the obligation of all countries to provide special care
and assistance for mothers and children.
In order to examine social protection schemes in LAC, it is important to
understand the context in which they came to be. Health systems in the
region were created based on a mix of European models of social protection. However, unlike in most European countries, health systems in
LAC were comprised of subsystems focused on the different health needs
of specific segments of the population, grouped according to income,
nationality, occupation, or social class (Acuña C., 2000 and 2005).
This development mirrored the highly unequal societal arrangements inherited from the Spanish/Portuguese colonization process, which created
a set of institutions benefiting the Spanish/Portuguese settlers and allowing
them to extract wealth from the indigenous population (The World Bank,
2006, 2:111-113; Inter American Development Bank, 2004 4:23-26).
Thus, the public/MoH managed subsystem undertook the health care
provision for the poor, sometimes inheriting private and public assistance
programs; the social security subsystem focused on workers in the formal sector and sometimes their families and dependents; and the private
subsystem specialized on the groups with higher incomes (Acuña C.,
11
BACKGROUND
2000; Rosenberg H. and Andersson B., 2000; PAHO/WHO, 2003; The
World Bank, 2006, 7:147). This segmented institutional arrangement still
persists in most of the countries of the region with the exception of Brazil,
Canada, Colombia, Costa Rica, Cuba, and several English speaking
Caribbean countries.
Fragmentation is also a characteristic of health systems in the region,
where multiple agents operate without coordination and often in competition with each other. The structural segmentation mentioned above;
weak governance; lack of integrated planning; often inadequate state
and non-state interactions; and inefficient referral mechanisms all lead to
the fragmentation of health systems (PAHO/WHO, 2003, ECLAC, 2005).
Fragmented systems create obstacles to the efficient use of resources and
the development of adequate standards of quality. Transaction costs increase, and it becomes difficult to guarantee the same level of attention
to populations affiliated to different SPHS. Health System’s segmentation
and fragmentation lead to inequity as well as inefficiency.
In addition, during the 1980s and 1990s, structural adjustment policies (SAPs), combined with the international oil crisis, the deterioration of
terms of trade, and civil wars, had a deep impact on the region’s social
and economic landscape. According to Milanovic (Milanovic B., 2005),
the period from 1980 to 2002 was a time of uneven global development. The average annual rate of growth for all countries, unweighted
by population, was only 0.7 percent per year, 2 percentage points less
than during the previous twenty years (1960-1980). Looking at individual
countries, this means that many failed to grow at all, or even experienced
negative growth, as the table below shows.4
4.
12
According to the same author, the average unweighted decrease in real per capita GDI between 1980 and 2002 among
countries that have a lower income in 2002 than in 1980 is 20 percent.
BACKGROUND
Table 2:
Winners and losers during the globalization era in LAC, 1980-2002
2002 real per capita GDI in relation to 1980 real per capita GDI
Country
More than 58% gain
Chile
Dominican Republic
Gain between 0 and 58%
Bahamas
Barbados
Brazil
Colombia
Costa Rica
El Salvador
Guyana
Jamaica
México
Panamá
Trinidad & Tobago
Loss between 0 and 20%
Argentina
Bolivia
Ecuador
Guatemala
Honduras
Paraguay
Peru
Uruguay
Loss over 20%
Haiti
Nicaragua
Venezuela
SOURCE: Adapted from Milanovic B. “Why did the poorest countries fail to catch up?” Carnegie papers. Carnegie Endowment for International Peace, N° 62, November 2005. Appendix 1, Page 30.
SAPs usually followed a set of prescriptions that were believed at the time
to be the best formula for economic growth. These policies encouraged
governments in the region to liberalize employment regulations, privatize
State-owned enterprises, decentralize services and budgets, deregulate
capital markets, and cut public expenditures. Facing strong pressure from
international financial institutions to reduce expenses, most governments
in the region reduced budgets for social programs. Franco-Giraldo et
al. (2006) analyzed the impact of SAPs on health indicators in LAC from
1980-2000 and found that the adoption of SAPs in the 1980s is linked
to a negative impact on social indicators, in the region, particularly those
related to the health situation. Furthermore, they conclude that the negative effects lasted into the next decade.
The decline in public expenditure on social programs was accompanied
by a decrease in per capita income and an increase in unemployment
and informal economic activity. As a result, SPHS provided both by the
13
BACKGROUND
Ministry of Health-managed subsystem and the Social Security institutions
became insufficient, leaving millions of people excluded from access to
health goods and services (Levcovitz E., Acuña C., 2003; ILO, 2003).
This translated into the high out-of-pocket expenditure on health that
reaches around 50% of total expenditure on health in several countries in
the region (PAHO/WHO, 2003). Studies show that when out-of-pocket
expenses are high, the ability to pay becomes the most important determining factor in whether or not an individual will seek health care (WHO,
2000 5:96-99; World Bank, 1993).
Table 3: Out-of pocket expenditure in health in the Americas, 2003
Country
14
ISO3
Private expenditure on health
as percentage of
total expenditure
on health
Out-of-pocket
expenditure
as percentage of private
expenditure
on health
Latest
Year
Out of pocket
expenditure
as a percentage of total
expenditure
on health
Antigua and Barbuda
ATG
29.4
100
2003
29.40
Argentina
ARG
51.4
55.6
2003
28.58
Bahamas
BHS
52.5
40.5
2003
21.26
Barbados
BRB
30.6
77.2
2003
23.62
Belize
BLZ
50.7
100
2003
50.70*
Bolivia
BOL
36
79.3
2003
28.55
Brazil
BRA
54.7
64.2
2003
35.12
Canada
CAN
30.1
49.6
2003
14.93
Chile
CHL
51.2
46.2
2003
23.65
Colombia
COL
15.9
47.2
2003
7.50
Costa Rica
CRI
21.2
88.7
2003
18.80
Cuba
CUB
13.2
75.2
2003
9.93
Dominica
DMA
28.7
100
2003
28.70
Dominican Republic
DOM
66.8
70.8
2003
47.29
Ecuador
ECU
61.4
88.1
2003
54.09*
El Salvador
SLV
53.9
93.5
2003
50.40*
Grenada
GRD
26.4
100
2003
26.40
Guatemala
GTM
60.3
91.9
2003
55.42*
Guyana
GUY
17.4
100
2003
17.40
Haiti
HTI
61.9
69.5
2003
43.02
Honduras
HND
43.5
85.8
2003
37.32
Jamaica
JAM
49.4
64.7
2003
31.96
BACKGROUND
Mexico
MEX
53.6
94.2
2003
50.49*
Nicaragua
NIC
51.6
95.7
2003
49.38*
Panama
PAN
33.6
82.2
2003
27.62
Paraguay
PRY
68.5
74.6
2003
51.10*
Peru
PER
51.7
79
2003
40.84
Saint Kitts and Nevis
KNA
36.2
100
2003
36.20
Saint Lucia
LCA
31.8
100
2003
31.80
Saint Vincent and the
Grenadines
VCT
32.5
100
2003
32.50
Suriname
SUR
54.2
51.8
2003
28.08
Trinidad and Tobago
TTO
62.2
88.6
2003
55.11*
United States of America
USA
55.4
24.3
2003
13.46
Uruguay
URY
72.8
25
2003
18.20
Venezuela (Bolivarian
Republic of)
VEN
55.7
95.5
2003
53.19*
* Out of pocket expenditure around or over 50% of total expenditure in health
SOURCES: Own computation based on data provided by WHO, including ‘World Health Statistics 2006’ and
‘The World Health Report 2006 Edition’.
By the mid 1990s, the idea that it was important to protect the poor from
the shocks and adversities associated with a globalized economy began
to gain momentum.5 Many governments in the region implemented a
series of health and education programs aimed at protecting vulnerable
populations. In addition, nearly all LAC countries had established the
right to universal and free health care in their Constitutions, even though
the transition from constitutional right to practice is still incomplete in
most countries. (Mesa-Lago, 2005).
5.
According to recent studies, globalization (understood as exposure to international markets) has been negatively correlated
with the allocation of resources to social programs. See Avelino et al. Globalization, Democracy, and Social Spending in Latin
America, 1980-1997, and Kaufman & Segura-Ubiergo, Globalization, Domestic Politics, and Social Spending in Latin
America: A Time-Series Cross-Section Analysis, 1973–97.
15
BACKGROUND
Table 4: Years when LAC governments enacted universal health care
Country
Argentina
Constitutional Right to Health
none
Specific Law
Law N°23.661 of 1989
Bolivia
Constitution of 1967
Presidential Decree N°25.265 of
1998
Brazil
Constitution of 1988
Law N°8.080 of 1990
Chile
Constitution of 1980
Law N°19.966 of 2005
Colombia
Constitution of 1991
Law N°100 of 1993
Costa Rica
none
Cuba
Dominican Republic
General Health’s Law N°5395 of
1973
Constitution of 1976
Law N°41 of 1983
none
Law N°87 of 2001
Ecuador
Constitution of 1996
Law N°80 RO 670 of 2002
El Salvador
Constitution of 1983
Legislative Decree 775 of 2005
Guatemala
Constitution of 1985
Social Development Law, Decree
N°42 of 2001
Guyana
Constitution of 1980
none
Haiti
Constitution of 1987
none
Honduras
Constitution of 1982
Health Code of 1991
Mexico
Constitution of 1917
General Health’s Law of 2003
Nicaragua
Constitution of 1987
General Health’s Law N°423 of
2002
Panama
Constitution of 1972
Law N°27 of 1998
Paraguay
Constitution of 1967
Law N°836 of 1980
Peru
Constitution of 1993
Law N°27.812 of 2002
Uruguay
Venezuela
none
Constitution of 1999
Law No. 18.211 of 2007
Degree 2944 of 1998
SOURCE: Own compilation based on the countries’ legal documents and secondary sources.
16
BACKGROUND
Countries in the region also adopted a series of health sector reforms (HSR) with a strong emphasis on cost-effectiveness and financial
sustainability and an increased role for the private sector. However, the
reforms did not achieve the expected results, and there is now a renewed
focus on the role of the state in guaranteeing social protection and equitable access to health care (FLACSO-World Bank, 2002; Levcovitz E.,
Acuña C., 2003; ILO, 2003).
Table 5: HSR in the 80’s and 90’s in LAC countries
Changes associated with HSR
Shortcomings
Separation of health system functions (steering role, provision, financing, insurance) occurred in many countries.
The private sector took on an increased role in the provision of insurance and health care.
The creation, promotion, and deregulation of
health insurance and provision markets led
to the proliferation of intermediate agents, all
competing among each other, as well as weak
or non-existent regulatory mechanisms, in turn
increasing fragmentation within the system, raising transaction costs and weakening the Ministry
of Health’s steering role in many countries.
Fiscal discipline was introduced in the public health sector. The importance of sustainable health financing was
emphasized. New sources of financing were sought.
Public expenditure on health was drastically reduced in most countries. The introduction of user
fees and other payment mechanisms at the point
of service increased out-of-pocket expenditure in
health in most countries.
Management of health facilities was improved in many
countries, in some cases through management contracts.
Efficiency and effectiveness criteria were applied to the
provision of health services.
Increasing competition among insurers and/or
providers, without effective state regulation,
deepened segmentation within the system. The
introduction of economic incentives related to
the provision of individual health services led to
a prioritization of curative care over preventive
actions.
Targeting mechanisms to expand coverage and reach
underserved populations were implemented.
The introduction of basic health packages for the
poor or specific population groups deepened
segmentation of health systems. The creation of
separate funds for those who can contribute and
those who cannot led to a loss of solidarity within
the system and increased inequity in access to
health care as well as in health outcomes. Coverage did not improve as expected.
Accountability in the management of health facilities,
quality of service, responsiveness to user’s needs, and
freedom of choice were recognized as central to the
performance of health systems. Patients’/users’ rights were
made explicit in many countries
Increasing demand for health services induced
by the promotion of users/patients’ rights was not
accompanied by interventions to improve health
services provision.
Decentralization of health management was implemented
in most countries to increase local participation.
Incomplete decentralization processes increased
lack of governance and geographic inequity in
the provision of health services.
SOURCE: Own compilation based on: Fleury, S. 2003; ILO, 2003; Levcovitz E., Acuña C., 2003; Levcovitz,
2006; Mesa-Lago, 2006; Sojo, A. 2001; World Bank, 2006; World Health Organization, 2006; ECLAC, 2005;
LAC Region countries Health Systems Profiles 2000-2006 PAHO/WHO
17
BACKGROUND
Although several countries in the region have long implemented SPHS
that aim at or include mothers and children, only recently have most
governments, largely influenced by the adoption of the MDGs, shown a
strong commitment to addressing the needs of these populations. Some
of them have done so in the context of wider social and economic initiatives as a part of the World Bank’s Poverty Reduction Strategy Programs (PRSPs), the International Monetary Fund-IMF’s Highly Indebted
Poor Countries-HIPC strategy or other initiatives carried out along with
the international community. This commitment has been translated into
the creation or improvement of a series of social protection in health
schemes in the region. While some countries have developed targeted
programs, as is the case in Bolivia, Ecuador, Peru, and Argentina, other
countries, such as Brazil and Chile, have strengthened their maternal and
child protection strategies within the broader setting of universal SPHS.
It is noteworthy that many countries have a mix of different interventions
aimed at protecting the health of mothers, newborns, and children.
18
CONCEPTUAL FRAMEWORK
3
CONCEPTUAL FRAMEWORK
3.1
DESCRIPTION OF SOCIAL PROTECTION
IN HEALTH SCHEMES SPHS CURRENTLY
IN PLACE IN THE REGION
3.1.1
WHAT IS A SOCIAL PROTECTION IN HEALTH
SCHEME SPHS ?
For the purposes of this study, a SPHS was defined as a public intervention aimed at allowing groups and/or individuals to meet their health
needs and demands through access to health care and/or other goods,
services or opportunities in adequate conditions of quality, opportunity,
and dignity, regardless of their ability to pay. This definition draws from
the PAHO/WHO-ILO’s ‘Extension of Social Protection in Health’ framework, which defines Extension of Social Protection in Health as “society’s
guarantee, through the different public authorities, that all individuals
or groups of individuals can meet their needs and demands in health
through adequate access to the services of any of the existing health
subsystems in the country, regardless of their ability to pay” (ILO-PAHO,
2005(6):40).6
What lies at the center of both definitions is the idea of securing access to
adequate health care –i.e. in adequate conditions of quality, opportunity,
and dignity - for all, without the economic situation of the individual or
his/her family being a barrier to access health care. According to Carrin
and James (Carrin G. and James C., 2004) this idea incorporates two
6.
PAHO-WHO Resolution CSP26.R.19 of September 2002.
19
CONCEPTUAL FRAMEWORK
different coverage dimensions: health care coverage (adequate health
care) and population coverage (health care for all). This idea also brings
into play a third dimension: financial protection (regardless of ability to
pay) through solidarity in financing.
The concept of social protection has changed over time. It first comprised
the notion of ‘safety nets,7 understood as “minimalist social assistance in
countries too poor and administratively weak to introduce comprehensive social welfare programs” (World Bank, 1993). Safety nets aimed at
providing public assistance to those who could not manage otherwise,
so as to keep people out of poverty by guaranteeing a minimum income
to meet basic needs (Bonilla and Gruat, 2003; Interamerican Development Bank- IDB, 2001). In this context, safety nets function as a temporary cushion against specific shocks, mainly through an income transfer
mechanism. As Unger et al. note, residual welfare - not solidarity – is
the value behind the concept of safety nets (Unger et al., 2006). This
approach also envisioned a limited role for government, usually favoring
solutions coming from civil society and the private sector.
Concerns for equity and human rights in the access to health care and
the magnitude and sustained character of poverty in some countries
forced a re-conceptualization of the notion of social protection in health.
Although the safety net approach is still widely applied, it fails to address
the structural determinants that generate vulnerability in the first place. It
also fails to recognize that the State can play an important role in managing mechanisms to increase and improve access to health care for
vulnerable populations (ILO, 2003).
With the expansion of wage labor in the late 19th and early 20th centuries, labor-related social protection schemes began to take shape to
cover a wider range of risks, such as unemployment, invalidity due to
age, workplace accidents or injury. Thus, social protection evolved from
having a primary safety net function, to a dual aim of protection against
and prevention of risks in the workplace. Over time, mechanisms for resource redistribution and pooling were introduced and consequently, the
concept of individual risk evolved into a collective approach to risk. Thus,
solidarity among the insured became a central aspect of social protection. Two models of social protection, one based on solidarity among
actors in the labor realm (Bismarkian) and the other based on solidarity
among the entire population (Beveridgian) would later be applied, in different versions, all over Europe and also in the developing world.
7.
20
The idea of social protection as a safety net can be tracked back to the English Poor Law, which was in place from 1598 to
1948.
CONCEPTUAL FRAMEWORK
In the 1990s, the World Bank developed a new approach to social
protection called ‘risk management’ (World Bank 1999; IDB 2000). It
focused on assisting individuals, households, and communities to manage risk, such as the risk of falling into poverty. Its health components
involved both reducing exposure to risks through targeted interventions
and alleviating their consequences through risk pooling in private or
informal insurance schemes. This approach relied on individual capacity to manage risk and its goal was individual wellbeing. It did not view
interpersonal redistribution of income as necessary to improve wellbeing
(Doryan et al. 2001 p.11).
Today, the growth of informal labor, the demographic changes associated with higher life expectancy, and greater mobility linked to migratory movements have compelled many countries in the industrialized and
developing world to re-examine their systems of social protection. To
better meet changing needs and to adapt to increasing vulnerability in
a global world, the concept of social protection in health needs to be
broadened (Bonilla and Gruat, 2003), to go beyond the ‘safety net’ and
“risk management” approaches - which rely solely on economic protection to cope with specific shocks - to address those factors, imbedded in
the social structure, that generate exclusion and inequity in the access to
health care (PAHO/WHO 2003; Levcovitz E., Acuña C. 2003; Jordan
B. 1996).
3.1.2
WHY ARE SPHS IMPORTANT?
Social Protection in health schemes matter. They play an important role
in improving access to health care. Although the existence of SPHS is
neither necessary nor sufficient to guarantee access to health care, they
remain one of the most important factors in improved access. Industrialized countries halved their maternal mortality in the early 20th century by
providing professional midwifery care at childbirth. They further reduced
it to current low figures by improving access to health care through the
implementation of Bismarkian or Beveridgian social protection schemes
(ILO, 2003). A number of developing countries have followed the same
path in the last few decades (WHO, 2005).
The Committee on the Consequences of Uninsurance in the USA found
that children without insurance are three times as likely as children with
coverage to have no regular source of care (Institute of Medicine, 2001).
One of the main roles of SPH Scheme is financial protection. As table 3
shows, in LAC countries with weak SPHS, out-of-pocket payments usually account for more than 50% of the total health expenditure. In these
countries, out of pocket expenses are much higher in the poorest quintile
and function as a main barrier to access health care (PAHO/WHO,
2003).
21
CONCEPTUAL FRAMEWORK
Gender also seems to play a role in out-of-pocket health expenditure:
household surveys that include individual health spending information
show that women’s out-of-pocket expenses are systematically higher than
men’s in Brazil (1996-1997), the Dominican Republic (1996), Ecuador (1998), Paraguay (1996) and Peru (2000) (United Nations, 2005;
ECLAC, 2005). Lowering out-of–pocket expenditure, especially among
the poor, is a stated goal of many interventions and is seen as a way to
eliminate the economic barrier to accessing health care and improving
health outcomes (WHO 2005, PAHO/WHO-ILO 2005, PAHO/WHO
2003).
3.1.3
BUILDING A TYPOLOGY OF SPHS AIMED AT OR IN
CLUDING MOTHER, NEWBORN, AND CHILD POPULA
TIONS CURRENTLY IN PLACE IN LAC COUNTRIES
Acknowledging the diversity of SPHS that aim at or include mothers,
newborns and children in the region, we grouped them into different
types according to the three dimensions that arise from the definition of
SPHS:
a. Health care coverage
b. Population coverage
c. Financial protection/Solidarity in financing
For each dimension several benchmarks, drawn from the literature and
relevant to the analysis of SPHS in the region, were selected. The report
drew especially on the work of D. Drechsler and J. Johannes (2005) and
F. Colombo and N. Tapay (2004) for the OECD on health insurance
schemes, as well as on the studies carried out by van Ginneken (1996)
and Bonilla and Gruat (2003) for the ILO in the field of social protection.
For the first dimension, health coverage, the following parameters were
selected:
1. Degree of coverage - i.e. whether the benefits/services portfolio
is comprehensive, complementary, or supplementary8
2. Existence of a portfolio of entitlements
3. Type of provision
8.
22
According to Mossialos and Thomsom, a complementary insurance package provides services excluded or not fully covered
by the state through regular channels whereas a supplementary or substitutive insurance package provides faster access
and increased consumer choice to services that are already covered by the state. See Elias Mossialos and Sarah Thomsom
“Voluntary health insurance in the European Union: a critical assessment” on the International Journal of Health Services
2002; 32 (1):19-88. A comprehensive insurance package is one that provides full coverage.
CONCEPTUAL FRAMEWORK
For the second, population coverage, the following parameters were
chosen:
1. Degree of selectivity, i.e. whether the SPHS is universal or targets
a specific group;
2. Population entitled to coverage
3. Conditions for access
4. Size of the risk pool
Concerning the third dimension financial protection/ solidarity in financing, the following parameters were used:
1.
2.
3.
4.
9.
Mode of financing
Source of funding
Type of risk pooling arrangement9
Resources management and management level - who manages
the resources and at what government level the resource management is carried out.
According to Sekhri and Savedoff, risk pooling arrangements may be community-rated – ie. transfers between healthy and
sick-; income-based –i.e. transfers between higher income and lower income individuals; -or individual risk-rated –i.e.
minimal risk transfer between individuals-. See N. Sekhri and W. Savedoff “Private health insurance: implications
for developing countries” WHO Bulletin 2005; 83 (2):127-34.
23
24
Income-based
Income-based
-General taxes
-Users’ fees
-Co-payments
-Premiums
-General taxes
-Informal workers’ voluntary
contribution
-Social security
contributions
General taxes
Social Health
insurance
Mother and
child health
Insurance
Extension of
social security to informal
workers
National
Health Insurance
-Communityrated
-Income-based
-Communityrated
-Income-based
-General taxes
-Social security
contributions
(payroll tax)
-Co-payments
Contributionbased insurance
scheme
Public Health
Insurance
Tax-financed
insurance
-Communityrated
-Income-based
-General taxes
-Individual
mandatory
contribution
-Individual
voluntary
contribution
-Co-payments
Risk pooling
arrangement
Source of
funds
Mode of
financing
Type
Targeted:
-Informal
workers and
in some cases
their families
Universal
National
Sub-national
-Provincial
governments
Individual
Individual /
Dependants
Individual
Targeted:
-Reproductive
age or pregnant women
-Children
under five
years old
National
Sub-national
Public Agency
MoH
Provincial governments
National
Sub-national
- Public Agency
- Social Security
Institution
Individual /
Dependants
Formal workers and their
families
National
-Public Agency
-Unions
-Tripartite: Govemployers- employees
Individual
Who is
entitled to
coverage
Universal
Degree of
selectivity
National
Ministry of Health
(MoH)
Management
and management level
Residence
Employment
status
-Age
-Proof of
pregnancy
-Proof of
delivery
-Means test
Employment
status
(Labor
contract)
Citizenship
Condition
for access
Large
pool
Large
pool
Small
pool
Large
pool
Large
pool
Extent
of risk
pooling
Explicit
Explicit
Explicit
Variable
(Explicit /
Not
explicit)
Explicit
Explicit
portfolio
Table 6: Typology of SPHS aimed at or including Mother, Newborn, and Child populations
Comprehensive
Complementary
Complementary
Comprehensive
Comprehensive
Degree of
coverage
Public
Private
Public
Private
Public
Public
Private
Public
Private
Type of
Provision
CONCEPTUAL FRAMEWORK
Publicly funded
social
assistance
Publicly
funded
health
programs
Tax-financed
health system
Mode of
financing
-Income-based
-Income-based
-General taxes
-Other revenues (IDB/WB
loans)
-General taxes
-Income-based
Local
MoH
Local gov.
Local
Local gov.
National
Sub-national
Local
MoH
Local gov.
National
Sub-national
Local
MoH
Local gov.
National
Sub-national
Local
MoH
Local gov.
-Communityrated
-Income-based
-Communityrated
Management
and management level
Risk pooling
arrangement
-General taxes
-Other revenues (IDB/WB
loans)
General taxes
General taxes
Source of
funds
Family
Family
Targeted:
Pregnant or
Lactating
mothers
Children under
5 years old
Disabled
children under
12 years old
Poor households
Targeted:
Pregnant
women
Lactating
mothers
Children under
6 or 5 years
old
Individual
Individual
Family
Individual
Who is
entitled to
coverage
Targeted: Reproductive age
or pregnant
women
Children under
five years old
Universal
Universal
Degree of
selectivity
Means test
Place of
residence
Age
Proof of
pregnancy
Means test
Age
Proof of
pregnancy
Proof of
delivery
Citizenship
Residence
Citizenship
Condition
for access
Small
pool
Small
pool
Small
pool
Large
pool
Large
pool
Extent
of risk
pooling
Explicit
Explicit
Explicit
Not
explicit
Not
explicit
Explicit
portfolio
Complementary
Complementary
Complementary
Comprehensive
Comprehensive
Degree of
coverage
Public
Public
Public
Public
Public
Private
Type of
Provision
SOURCE: Own compilation based on categories proposed by Drechsler D., Johannes J., (2005); and Colombo F., Tapay N., (2004) for the Organization for Economic
Cooperation and Development-OECD and by W. van Ginneken (1996); and Bonilla and Gruat (2003) for the International Labour Office-ILO.
Conditioned
in-kind
transfer
Conditioned
cash transfer
Free maternal and child
care
Free primary
health care
National
Health system
Type
CONCEPTUAL FRAMEWORK
25
CONCEPTUAL FRAMEWORK
According to the typology, some of the SPHS currently in place in the
region can be classified as follows:
Table 7: Social Protection in Health Schemes (SPHS) aimed at or including mothers, neonates and
children in the Americas
Type
Example
Country
Public Health Insurance
-Fondo Nacional de Salud
-Seguro Popular de Salud
Chile
Mexico
Social Health Insurance
-Caja Costarricense de Seguridad Social
-Instituto Guatemalteco de Seguridad Social
-Instituto Mexicano de Seguridad Social
-MEDICARE
Costa Rica
Guatemala
Mexico
USA
Extension of social security to informal
workers
-Seguro Social Campesino
-IMSS (Instituto Mexicano de Seguridad
Social)-Solidaridad
Ecuador
Mexico
National Health Insurance
-National Health Insurance
Aruba, Bahamas,
Canada
National Health System
-Sistema Único de Saúde
-Ministry of Health(*)
Brazil
Barbados, Belice,
Cuba, Nicaragua,
Venezuela
Free primary health care
-Programa Saúde da Família
-Programa de Salud Familiar
-Programa Barrio Adentro
Brazil
Chile
Venezuela
Free maternal and child care
-Ley de Maternidad Gratuita y Atención a la
Infancia
-Seguro Universal Materno-Infantil
-Seguro Provincial Materno-Infantil
-Seguro Integral de Salud
Ecuador
Bolivia
Argentina
Peru
Conditioned cash transfer
-Bono materno-infantil
-OPORTUNIDADES Program
-Bono Solidario
-Bolsa Familia
Honduras
Mexico
Ecuador
Brazil
Conditioned in kind transfer
-Plan Nacional Alimentación Complementaria
-Plan Nacional Alimentación Complementaria
-Vaso de Leche Program
Chile
Argentina
Peru
SOURCE: Own compilation based on secondary sources
(*) Most of Latin American countries have a National Health System run by the Ministry of Health
26
CONCEPTUAL FRAMEWORK
3.2
ANALYSIS OF THE STRENGTHS AND
WEAKNESSES OF THE SPHS
3.2.1
THE CHALLENGE OF MEASURING SPHS PERFOR
MANCE
The assessment of public health interventions that provide social protection in health is intrinsically difficult due to the various factors involved
in their design, implementation, and outcomes. Moreover, there is no
standard method to evaluate the impact of public health interventions in
general - let alone public interventions focused on extending protection
in health to mothers, newborns, and children- other than approaches
used within the cost-benefit analysis framework (Kelly M., McDaid D.,
Ludbrook A., Powell J., 2005). Some of the challenges posed by the
performance analysis of SPHS are:
1. SEPARATING CAUSE AND EFFECT. Unlike drug-based and other clinical interventions, public health interventions such as SPHS use different
strategies and mechanisms to tackle multi-causal and complex problems,
making it difficult to identify which elements of the scheme are responsible for which, if any, changes. The effects of mediating or confounding
factors at the point of implementation in real-word settings need to be
considered. Kelly et al. state that the variable effectiveness and success of
interventions are filtered through two sets of mediating factors which are,
to some extent, independent of the mechanisms of the intervention itself.
These are the enthusiasm, expertise, and engagement of the staff carrying out the intervention and the local delivery infrastructure (Kelly M.,
McDaid D., Ludbrook A., Powell J., 2005). Even when interventions are
well defined and highly circumscribed their performance and outcomes
strongly depend on institutional and other contextual factors, as it can
be observed when comparing the impact of almost identical mother and
child health and nutrition programs in two relatively similar countries,
Chile and Argentina, along the same period of time (Idiart A., 2004).
2. ASSESSING THE INFLUENCE OF THE SOCIAL, POLITICAL AND
INSTITUTIONAL CONTEXT ON PERFORMANCE. The context in which
SPHS are implemented may be highly influential to their achievements
and shortcomings. As Travis et al. note, the overall policy environment,
political instability, and the quality of governance are some of the factors
outside the health system that may impact health service delivery. Some
findings suggest that in certain countries these broad policy and institutional constraints pose greater barriers than resource constraints (Travis
P et al., 2004). Furthermore, the socioeconomic context has implications
for how public health interventions are designed and evaluated and must
be taken into account in the analysis (Levcovitz E., Acuña C., 2003; Kelly
M., McDaid D., Ludbrook A., Powell J., 2005).
27
CONCEPTUAL FRAMEWORK
3. IDENTIFYING WHICH ASPECTS SHOULD BE EXAMINED WHEN ASSESSING SPHS. The ultimate target of SPHS - securing access to adequate health care for all regardless of ability to pay - is often a long
term goal, posing the need for identifying indicators that may be used
as proxies of progress in the short, intermediate, and long term. Any
assessment of SPHS aimed at or including mother, neonatal, and child
health must examine a) the impact of the SPHS on the main health determinants of the target populations; b) the mechanisms for addressing
inequities in the access to and the utilization of health services, and c) the
extent to which the SPHS improves the provision and quality of specific
interventions highly correlated with MNCH, such as care during delivery
by skilled personnel.
4. MAKING CROSS-COUNTRY COMPARATIVE ANALYSIS. If assessing
the performance of a given SPHS is difficult, undertaking a comparative
analysis among several SPHS in different countries poses huge methodological challenges. As Travis et al. point out, cross-country comparative analysis is one of the most contentious issues in health systems and
services research, since health systems operate in such different contexts
(Travis P. et al., 2004). In addition, SPHS in different countries are in different stages of maturity, further complicating cross-country comparisons
since the effectiveness of a given scheme may be influenced by its evolution over time.
3.2.2
TOWARDS A BASELINE FOR THE ANALYSIS OF SPHS
AIMED AT OR INCLUDING MOTHER, NEWBORN, AND
CHILD POPULATIONS
3.2.2.1 LAYING OUT THE FOUNDATIONS
Despite the constraints mentioned above, there is an urgent need to learn
which SPHS, and under what conditions, perform best in protecting the
health of mothers, newborns, and children, in order to inform and support the policymaking process in the countries of the region. Currently,
there is no analysis of lessons learned in the area of SPHS for mother,
newborn, and child populations in Latin America, and it is therefore necessary to build a baseline for assessing SPHS.
A good starting point is a descriptive analysis of strengths and weaknesses, taking into account the socio-political context as well as key environmental factors that affect MNCH. The analysis will be based on
four principles, selected for their well-documented importance for SPHS
performance as well as MNCH (ECLAC, 2005; Interagency Strategic
Consensus for Latin America and the Caribbean, 2003; WHO, 2005;
UN Millennium Project, 2005). The principles are:
28
CONCEPTUAL FRAMEWORK
I.
II.
III.
IV.
Equity is central to MNCH, as well as to achieving the goal of
“health for all.” Improving equity in the access to and/or the utilization of health services, as well as in health outcomes, should be
one of the goals of any SPHS focusing on MNCH.
MNCH is strongly linked to social determinants of health, which
also have a deep impact on the performance of SPHS. Social determinants may help to reduce disparities in health or be a source
of inequity in health, since mothers and children that are poor,
socially excluded, malnourished, and lacking adequate access to
food, water, and sanitation are more likely to suffer from disease
and less likely to have the resources to seek - and obtain - timely health care. SPHS should be instrumental in offsetting social
determinants that damage health and/or hinder the demand for
health care.
Improving quality and coverage of technically appropriate interventions is crucial to achieving better outcomes in MNCH. There
is a growing consensus that for this to be possible, health systems
must be strengthened and their capabilities in key areas such as
the health workforce, drug supply, health financing, and information systems must be increased. SPHS can play a role in strengthening health systems by implementing comprehensive and integrated strategies to improve quality and coverage of technically
appropriate interventions highly related to maternal, neonatal,
and child health.
Context matters in the performance of SPHS. The analysis of SPHS
must be rooted in their social, political, and economic context.
I. EQUITY IS A CENTRAL ISSUE FOR MNCH
The concepts of equity/inequity in health are rooted in the framework of
Rawls’s (1971) Theory of Distributive Justice, which develops the idea that
all social primary goods - liberty and opportunity, income and wealth,
and the bases of self-respect - are to be distributed equally, unless an
unequal distribution of any or all of these goods is to the advantage of
the least favored.
From the idea mentioned above, it follows that there are at least three
principles of equity in health that need to be achieved (Oliver and Mossialos 2004):
1. Equal access to health care for those in equal need of health
care
2. Equal utilization of health services for those in equal need of
them
3. Equitable health outcomes
29
CONCEPTUAL FRAMEWORK
Each of these three principles requires the satisfaction of different conditions which make them more or less suitable for operational policy objectives within the scope of the health sector.
1. Equal access for equal need is related to the supply side of heath care
and requires conditions whereby:
a) Those with equal needs - for example, all the people who need
treatment for diabetes - have equal opportunities to access
health care (this is called “horizontal equity”); and
b) Those with unequal or different needs - for example all the diabetic women who are also pregnant - have appropriately unequal opportunities to access health care (this is called “vertical
equity”).
2. Equal utilization for equal need is related to the demand side of health
care and requires that those who have an equal need for health services
make equal use of those services. It is worth noting that satisfying this
principle may require that potentially acceptable reasons for unequal use
of health services by those in equal need - for example, differences in
lifestyle, beliefs, or levels of risk aversion - be overridden.
3. Achieving equitable health outcomes requires not only the satisfaction
of the first two principles but also the active participation of other areas of
fiscal and social policy that impinge upon income, employment, education, housing, nutrition and other social macro determinants of health.
Although there are different methods for measuring inequities in health,
the measurement of socioeconomic inequities, using income as the ranking variable for individuals and groups is the most widely used, perhaps
because of the importance of poverty and income distribution as determinants of inequity in health. Comparing the health outcomes of the
richest and the poorest quintiles provides strong evidence to support the
statement that the health of mothers and children is strongly linked to equity (Wagstaff 2004; Bergman L, Kawachi I, 2000; Shen C., Williamson
J., 1999; Daniels N., Kennedy B., Kawachi I., 2000).
30
CONCEPTUAL FRAMEWORK
Graph N. 1
120
Latin America and the Caribbean (Selected Countries):
Infant Mortality Rates, By Income Quintiles, 1999
100
80
B razil
B olivia
C olom bia
G uatem ala
H aití
60
40
20
0
Q uintile I
Q uintile 2
Q uintile 3
Q uintile 4
Q uintile 5
SOURCE: D.R. Gwatkin and others, Socio-Economic Differences in Health,
Nutrition and Population in Selected Countries, Washington, D.C., World
Bank, quoted in Pan American Health Organization (PAHO), Health in the
Americas, 2002 edition, Washington, D.C., 2002.
Rising inequalities in the access of mother, newborn, and child populations to health care explain the slow progress, the stagnation and,
in some cases, the backward trend in maternal, neonatal, and infant
mortality rates registered throughout the world, despite the existence of
effective interventions to prevent or to treat the main causes of maternal
and child deaths (WHO, 2005). In the LAC region, for example, despite
advances in the reduction of infant mortality, the trends in neonatal mortality have shown practically no improvement over the past ten years in
a number of countries. This stagnation has brought increasing attention
to the plight of newborns and calls for greater efforts to reduce these
unnecessary deaths (Interagency Strategic Consensus for Latin America
and the Caribbean, 2007).
Approximately 11,624,300 children are born in LAC every year, of which
348,729 die before reaching their first year of age. About 174,364
deaths occur during the neonatal period, and 60% of neonatal deaths
occur during the first week of life. The newborns mainly die from infections (32%), asphyxia at birth (29%), prematurity, and low birth-weight
(24%). About 10% die from congenital anomalies. Infant mortality
(deaths between 0-11 months) is a sensitive indicator of the general
health conditions in a given country and is therefore often used as a
measure of inequity (Royston and Armstrong 1989; WHO 1996; Shen
and Williamson 1999).
31
CONCEPTUAL FRAMEWORK
Moreover, maternal death rates are also higher in the poorest countries than in the richest, and within countries they are significantly higher
among the disadvantaged, the poor, the indigenous, and those who live
in rural areas (PAHO/WHO 2004; WHO 2005). Maternal ill health is
the largest contributor to the disease burden affecting women in developing countries (Castro and Camacho 2004). Furthermore, rates of maternal mortality show a greater disparity between rich and poor nations
than any other public health indicator (Shen and Williamson, 1999). In
Bolivia, for example, coverage of institutional births in 1998 was only 39
percent in the poorest quintile, compared with 95 percent in the richest
quintile (IADB, 2004).
It has been estimated that more than half of global under-five deaths are
attributable to five conditions, namely diarrhea, pneumonia, measles,
HIV-AIDS, and malaria (Caulfield and Black 2002). Malnutrition is associated with 60% of these deaths. These conditions disproportionately
affect the poor. The under–five mortality rate currently averages 6 per
1000 live births in the industrialized countries, but is as high as 274 in
the developing world, and 119 in LAC (WHO, 2005). Moreover, the
gap in under-five mortality rates between the rich and the poor within
countries has widened in at least four LAC countries between 1986 and
2000 (WHO, 2005).
II. MNCH IS STRONGLY LINKED TO SOCIAL DETERMINANTS OF
HEALTH
Since the seminal work of Marmot and Wilkinson in the eighties, the importance of social determinants of health - defined as all the non-genetic
and non-biological influences on health - to the health status of population has come to be widely recognized, especially as a source of disparities between the disadvantaged and the better-off in society (Marmot and
Wilkinson, 1999; Berkman and Kawachi, 2000). The concept of social
determinants of health comprises individual risk factors - such as risky
behaviors - and also the so-called “wider determinants” that in turn include social, cultural, and environmental factors, such as social position,
education, gender, ethnicity, income, employment, housing, and social
exclusion (WHO, 2003; Wanless, 2004; Graham, 2004).
The importance of social and economic conditions to maternal and child
health has long been acknowledged. Infant mortality reduction over the
last fifty years has been mostly related to improvements in socio-economic circumstances and in living conditions (Rashad H., 1994). During
the 1970s, socioeconomic development and improved basic living conditions - namely access to clean water, sanitation, and nutrition - started
to be seen as the keys to improving child health (WHO, 2005 p. 103).
32
CONCEPTUAL FRAMEWORK
There is also a sound body of information indicating that child health
largely depends on the health status and education of the mother and
on family income (Marmot M, Wilkinson R., 1999; Save the Children,
2005; Holmes J., 2002; Wamami et al, 2004). Regarding maternal
health, Shen and Williamson (1999) found that women’s status, as measured by indicators such as level of education relative to men, age at first
marriage, and reproductive autonomy, is a strong predictor of maternal
mortality.
Table 8: The social context of raised risk to health in early life
•
Poverty
•
Income inequality
•
High rates of unemployment of both parents
•
High degree of family discord
•
Gender-biased and generally restricted opportunities for education, and low levels of literacy, especially
for women
•
Low levels of contraceptive use and/or breast feeding
•
Isolation of women from the mainstream of social participation, and from legal and social security
SOURCE: “Social determinants of health” edited by Michael Marmot and William Wilkinson. Oxford University
Press, 1999, Chapter 3, pages 44-57.
In 1998, UNICEF (United Nations Children’s Fund) devised a conceptual model for understanding child morbidity and mortality. It states that,
amongst other factors, the political, social, and economic systems that
determine how resources are used and controlled need to be considered
so as to determine the number and distribution of children who do not
have enough access to food, child care, clean water and sanitation, and
health services. This model is also applicable to maternal health and
highlights how the distribution of power, political influence, and economic resources shape the pattern of health globally (Global Health
Watch, 2005). The model identifies the quantity, quality and allocation
of resources as basic causes of child malnutrition, death and disability
at societal level and insufficient access to food, inadequate maternal
and child care, poor water/sanitation and inadequate health services as
underlying causes at household/family levels.
Graham (2004) also proposes a model of how key health determinants
connect to each other. In his conception, health care and social services
act as intermediary determinants of good health, due to their role in
preventive care as well as their contribution to reducing the impact of
33
CONCEPTUAL FRAMEWORK
illness and injury and providing care and support to those with disabling
conditions. On the other hand, when the costs associated with health
care services push people into poverty or deepen already existing poverty, the health system itself becomes a cause of poverty and, therefore a
determinant of ill health (WHO-EURO, 2003, p.13).
Health interventions may also offset or reduce the negative effects of
other determinants of health. For example, Holmes argues that access to
and quality of community health facilities tend to substitute for household
wealth and mother’s education in the production of child health and that
public health infrastructure, such as piped water and sanitation, tends to
complement mother’s education in the production of child health (Holmes J., 2004). Along the same lines, Barros et al. propose that well
designed health interventions can reduce the damaging effect of poverty
on child health (Barros et al., 2005).
Thus, it can be argued that in order to achieve their goals, SPHS must be
able to offset social determinants that worsen health status and/or hinder
the demand for health care.
III. IMPROVING QUALITY AND COVERAGE OF TECHNICALLY
APPROPRIATE INTERVENTIONS IS CRUCIAL TO ACHIEVING
BETTER OUTCOMES IN MNCH
While maternal and child health is to a great extent determined by factors
outside health sector, timely access to and the quality of health services
play a crucial role in maternal, child, and neonatal mortality (Iunes R.,
2001; PAHO/WHO, 2003; Interagency Strategic Consensus for Latin
America and the Caribbean, 2003; WHO, 2005). Several studies show
that the main determinant of maternal and neonatal mortality is the delay
in accessing adequate care provided by trained personnel during childbirth and postpartum (Interagency Strategic Consensus for Latin America
and the Caribbean, 2003; PAHO/WHO, 2004; WHO, 2005).
Social exclusion in health refers to the lack of access of certain groups
or people to various goods, services, and opportunities that improve or
maintain their health status and that other individuals and groups in the
society enjoy (PAHO/WHO, 2003). It is a multi-causal phenomenon affected by causes within and outside the health system. Access - understood as the capacity of the individual who has the health need to come
into contact with the mechanisms aimed to satisfy his/her health needs
- is to a great extent determined by coverage - defined as the provider’s
ability to supply the adequate health goods and services to those who
need them. Thus, in order for access to occur, two conditions are required:
34
CONCEPTUAL FRAMEWORK
a) The individual who has the health need should possess the
means for coming into contact with the provider of the goods/
services aimed at satisfying that need (demand side).
b) The provider should be able to make available the service or
good required (supply side).
There are several factors inside and outside the health system that affect
the availability of health goods and services in the Region. Within health
systems, these factors lie:
a) In the health systems’ architecture, namely the degree of segmentation and fragmentation;10
b) In the way that interventions are organized and resources allocated;
c) In the geographical distribution of the service delivery network.
a) Health system’s segmentation and fragmentation.
In segmented systems, the coverage and quality of health interventions
are higher for population groups with higher income and social position
(PAHO/WHO-SIDA, 2003; Behrman, Gaviria and Székely, 2003; Acuña
C., 2005). Improvement in economic status does not alter this situation;
data show that in highly segmented health systems, as countries move
from a pattern of massive deprivation toward one of marginalization, the
poor-rich gap in health servicies coverage and utilization grows in size,
to diminish only when universal access is within reach. Unless specific
measures are implemented to extend coverage and promote utilization
across all population groups simultaneously, improvement of aggregate
population coverage will go through a phase of increasing inequality
(WHO, 2005 2:29-30).
Fragmentation hinders coverage and quality of health services because
the existence of various agents operating without coordination makes it
difficult to standardize the quality, content, cost, and application of interventions and prevents building effective referral mechanisms. Studies
in Bolivia, Brazil, El Salvador, Honduras, and Nicaragua show that one
of the main problems in implementing successful interventions to reduce
maternal mortality is the difficulty of applying them at different territorial levels due to the fragmentation within the public subsystem (PAHO/
WHO-USAID, 2004).
10.
The following definitions were adopted for segmentation and fragmentation: Segmentation is the coexistence of various
health subsystems with distinct financing, affiliation, and provision arrangements “specialized” for different segments of the
population according to their income level and social position. Fragmentation is the existence of many non-integrated entities
and/or agents within the whole system or in a subsystem that operate without synergy and often competing among each
other.
35
CONCEPTUAL FRAMEWORK
Segmentation and fragmentation largely influence the way interventions
are organized, resources are allocated, and the service delivery network
is geographically distributed.
b) Resource allocation and organization of health interventions.
Health systems in most LAC countries face serious problems of scarcity and poor distribution of resources. The greatest shortcomings lie in
the allocation, distribution, and training of human resources and in the
amount and distribution of public spending (ECLAC, 2005 V: 157-71).
The latter also account for the lack of adequate drug supply and information systems.
There is ample evidence that the size and quality of the health workforce
are positively associated with immunization coverage, outreach of primary care, and child, neonatal, and maternal survival (WHO, 2006).
However, few countries in the Americas have succeeded in implementing
appropriate human resources policies, and countries have demonstrated
enormous diversity in the skill mix of health teams. Again, segmentation
and fragmentation of health systems has led to persistent imbalances
in human resources distribution and asymmetrical growth in personnel
supply and demand across the public subsystem, social security organizations and the private sub sector. Inequality exists between regions
inside the countries, as well, with the health workforce concentrated in
rich urban areas (PAHO/WHO, 2003).
The public subsystem offer few incentives to trained professionals to work
in poor or rural communities where the rates of maternal mortality are
the highest. Moreover, the skills of personnel attending births vary greatly, and many do not have the expertise necessary to provide adequate
treatment for obstetric emergencies (Interagency Strategic Consensus for
Latin America and the Caribbean, 2003 2: 28-33). A sizable number of
countries in the Region do not have the necessary workforce to provide
minimum coverage.11 In countries with a low density of health personnel,
under-five mortality rate is around 43 per 1,000; maternal mortality ratio
reaches 148 per 100,000 and deliveries attended by skilled personnel
do not exceed 74% (PAHO/WHO, 2006).
Overall public spending in health is lower in LAC countries than in the
developed world. Moreover, in LAC countries with highly segmented
health systems, public spending in health is regressive, leading to higher
out-of-pocket spending in the poorest households (PAHO/WHO, 2003;
ECLAC, 2005 V:160-61; PAHO/WHO: Basic Indicators 2005). Only
11.
36
25 professionals per 10,000 population, according to WHO’s Joint Learning Initiative.
CONCEPTUAL FRAMEWORK
Costa Rica, Chile, and Uruguay show a progressive pattern of public
spending that benefits lower income groups (ECLAC 2005 V: 160-61).
When public spending is low and regressive, it is difficult to assure sustainable financial support for maternal and child care to low-income
populations.
c) The geographical distribution of the service delivery network and health
infrastructure.
The concentration of infrastructure for health care delivery in the wealthiest urban areas in many LAC countries leads to lack of coverage in poor,
rural, and isolated territories. For example, basic Essential Obstetric
Care (EOC) facilities are often unavailable in these areas, thus leaving
those living in them - often poor people and of indigenous origin- excluded from access to health care (Interagency Strategic Consensus for
Latin America and the Caribbean, 2003 2: 28-33).
Thus, women are faced with few choices for perinatal care and childbirth. They can either deliver at home or travel to a distant hospital. For
women living in rural areas, traveling is often expensive, both in terms
of transportation costs and of time away from their families and work.
The imbalance that results from the concentration of the service delivery
network and medical care in the richest regions is a main cause of maternal and/or child mortality in Bolivia, Brazil, Ecuador, El Salvador, Honduras, Guatemala, and Mexico (PAHO/WHO, 2003; Flores W., 2005;
Schwartzman S., 200612; World Bank, 2006 7:142-48).
IV. CONTEXT MATTERS IN THE PERFORMANCE OF SPHS
As mentioned in section 3.2.a, SPHS are neither created nor function
in a vacuum. The social, political, and economic context in which the
schemes are designed and implemented, including factors such as institutional capacity, governance, and gender and ethnic issues, may have a
strong influence on the overall performance of the scheme. Furthermore,
it is important to bear in mind that to be sustainable, a given SPHS must
take into account how society conceives of the State and its welfare function.
Governance can be defined as the exercise of political, economic and
administrative authority in the management of a country’s affairs at all
levels (UNDP, 1997),13 and as the art of steering societies and organizations, including the process whereby, within accepted traditions and
12.
13.
Simon Schwartzman. Presentation made at the Conference “The Struggle for Social Inclusion in Brazil. Policies to Combat
Poverty and Inequality” at the Wilson Center, Brazil Program in Washington, DC February, 2006
Op. Cit. 3
37
CONCEPTUAL FRAMEWORK
institutional frameworks, interests are articulated by different sectors of
society, decisions are made, and decision makers are held accountable
(Plumptre and Graham, 2000). By either definition, governance is key
to shaping SPHS in an organic way by establishing public agreement on
what must be done, bringing stakeholders together for structured negotiations, providing the institutional framework for the SPHS to function,
and promoting solidarity in society. Weak governance capacity prevents
SPHS from fulfilling their potential and undermines their sustainability
over time.
The organization and functioning of SPHS requires solid public institutions, at all levels, that can be held accountable for the decision making
process and are responsive to the population’s needs. This includes parliamentary oversight, a fair and transparent judiciary system, and strong
and clear administrative rules to ensure that public resources are allocated and spent to achieve maximum impact on health outcomes and
not lost through corruption or mismanagement (DFID, 2005). Lack of accountability, monitoring, and/or evaluation of social protection in health
policies limits the possibilities of feedback and obstructs results-based
management of resources, causing inefficient spending in programs that
are not accomplishing their stated goals.
38
CONCEPTUAL FRAMEWORK
Table 9: Causes of exclusion in health
Dimension
Cause
Area
Segmentation, Fragmentation
Architecture of the
system
a. Health system is divided into
subsystems specialized for population
groups according to income and social
position
b. Agents within the system operate
without integration in a non-synergistic
fashion
Poor regulation/enforcement
Organization of the
system
Inability to enforce compliance with
rules and regulations
Deficit of infrastructure
Health goods and/or
services provision
Lack/ shortage of health facilities
Internal to
health system
Inadequate resource allocation/distribution
Low quality of care, leading to self exclusion
External to
health system
Category
Barriers that prevent access to health care
Health goods and/or
services provision
Lack/ shortage of human and/or
technological resources, drugs, medical
devices, equipment
a. Technical quality
b. Contact at the
point of service
a. Errors in diagnosis and/or treatment
that result in lack of access to needed
care
b. Disrespectful treatment of the public,
discrimination, untidy facilities
Geographical
Geographical isolation
Economic
Inability to purchase health care
Cultural/ethnic
Health care is delivered in a language
or in a modality that is not understood
by the user or that is in conflict with
his/her beliefs
Gender
Health care is delivered without proper
consideration of specific gender needs
Employment status
Underemployment, informal employment, unemployment
Public infrastructure
other than health
sector’s
Lack/shortage of drinkable water, sewerage systems, roads, transportation
Provision of goods
and/or services that
affect health status
Lack/ shortage of refuse collection
SOURCE: Adapted from “Exclusion on health in Latin America and the Caribbean” PAHO/WHO, 2003
39
CONCEPTUAL FRAMEWORK
Gender and ethnicity are also important in the implementation of social
protection policies. Women, as caretakers and head of households, are
more likely to be affected by changes in social policies, since they can
dramatically alter the balance between paid labor and domestic labor
(Research on Poverty Alleviation-REPOA, 2006). In addition, in ethnically
diverse countries such as those in Latin America, the SPHS not only has
to devise mechanisms to tackle discrimination, but must also adapt the
provisions of health care to various cultural preferences and beliefs.
Economic context - namely, the level of public spending, the ability to collect tax revenues, the degree of economic growth and macroeconomic
stability, and most importantly the poverty level - certainly shapes social
policies and especially social protection policy in the Region. The growing trend of collecting revenues through indirect cumulative taxes (sales
taxes) with low distributive impact, and the failure to implement fiscal
reforms, has left many countries of the Region with a weak capacity for
redistribution and a highly regressive system of taxation (ECLAC, 2005).
3.2.2.2 HOW THESE PRINCIPLES INTERACT
To achieve the goal of guaranteeing “that all individuals and groups of
individuals can meet their needs and demands in health trough adequate
access to services… regardless of their ability to pay,” the SPHS must be
able to increase equity in the access to and utilization of health services,
thwarting social determinants that may determinate status and/or deter
the demand for health care for the disadvantaged groups in society. It
must also have the ability to improve quality and coverage of technically
appropriate interventions, confronting the factors that restrict the provision of health care for those who need it. To a great extent, the social
and institutional context determines the ability of the SPHS to achieve
those goals, posing constraints to their performance and defining how
the SPHS are designed and evaluated.
The interaction of the key elements described can be diagrammed as
follows:
40
CONCEPTUAL FRAMEWORK
SOCIAL, POLITICAL AND ECONOMIC CONTEXT
ˆ
Social Protection in Health Scheme-SPHS
ˆ
ˆ
Health care
System
- Segmentation
- Fragmentation
- Quality
- Infrastructure
- Resource distribution
- Financing
ˆ
ˆ
ˆ
ˆ
ˆ
ˆ
ˆ
ˆ
ˆ
Health
Health
Perceived ˆ
ˆ Health
demand ˆ
need ˆ
condition
Demand is
Not
expressed
perceived
Access Barriers
ˆ
ˆ
ˆ
ˆ
ˆ
Demand
is held
ˆ
ˆ
ˆ
Social determinants of health (Enabling/Hindering)
Education- family income- geographic accessibility- access to
water/sanitation/electricity- ethnic background/culture – woman’s’ status – social class – distribution of power – labor status
– institutional fragility - governance
ˆ Health outcomes
41
ANALYTICAL FRAMEWORK
4
ANALYTICAL FRAMEWORK
4.1
OBJECTIVE
The objective of the analysis is to identify and describe different
SPHS currently in place in LAC countries as they relate to MNCH, and
to develop a comparative analysis of their strengths and weaknesses,
based on the conceptual framework developed on Chapter 3. The steps
included in the analysis are:
1. Characterization of the SPHS
2. Characterization of the general setting in which the SPHS is
implemented
3. Analysis of the strengths and weaknesses of the SPHS based
on its compliance with the following parameters:
a)
b)
c)
42
Increase equity in the access to and/or
utilization of health services;
Offset social determinants that deteriorate
health status and/or hinder the demand for
health care; and
Extend coverage of and increase access to
technically appropriate health interventions by
reducing or eliminating one or more causes of
exclusion.
ANALYTICAL FRAMEWORK
4.2
METHOD
A cross-sectional descriptive analysis based on a literature/internet review and secondary sources was conducted. Seven SPHS were selected
for analysis based on availability of reliable information and the scheme’s
relative importance within the country, as measured by the resources allocated to it as well as its priority on the public agenda.
4.2.1.
CHARACTERIZATION OF THE SPHS
Each of the seven SPHS under analysis was characterized according to
the criteria listed in Table 6 and the typology developed in section 3.1 of
this document.
4.2.2
CHARACTERIZATION OF THE GENERAL SETTING IN
WHICH THE SPHS IS IMPLEMENTED
A matrix was created to analyze the conditions surrounding the SPHS.
The matrix was based on Marmot and Wilkinson’s Social Determinants
of Health framework - which was explained in the previous chapter and on the contextual/political factors most frequently associated with
health conditions, namely institutional fragility/strength and governance
as related to political stability/instability. The analysis is qualitative and
therefore does not intend to provide a quantitative measure of how the
selected social determinants affect health status and demand for health
care. To build the matrix, the following criteria were used:
43
ANALYTICAL FRAMEWORK
Table 10: Criteria to examine the effect of context on health status and demand for health care
Contextual factor
Situation
Health Status
Demand for
health care
deteriorates
hinders
Poverty: people living under
the poverty line % of total
population
High >= 30%
Low < 30%
improves
promotes
Education level: literacy
rate %
High >= 70%
improves
promotes
Low < 70%
deteriorates
hinders
Numerous >= 30% total
population living in rural/remote dwelling
deteriorates
N° of rural dwelling/remote
settlements
Access to tap water, sanitation, and electricity
Government institutions
Country’s governance
Unemployment
hinders
Few < 30% total population living in rural/remote
dwelling
improves
Full >= 70% total population covered
improves
hinders
Scarce < 70% total population covered
deteriorates
hinders
strong
improves
promotes
fragile
deteriorates
hinders
improves
promotes
Politically instable
deteriorates
hinders
High >=25% of total working population
deteriorates
hinders
Low < 25% of total working
population
improves
promotes
High > 50% of total jobs
deteriorates
hinders
Low < 50% of total jobs
improves
promotes
Politically stable
promotes
Labor informality
Therefore, the country’s general situation matrix - as shown in table 11
- must be interpreted based on the criteria selected on table 10.
44
ANALYTICAL FRAMEWORK
Table 11: Country’s general setting (context)
Contextual factor
Health status
deteriorates
improves
Demand for health care
hinders
promotes
Poverty level
Education level
No. in rural dwelling/remote settlements
Access to tap water/sanitation/electricity
Government’s institutions
Country’s governance
Unemployment rate
Labor informality rate
4.2.3
ANALYSIS OF THE STRENGTHS AND WEAKNESSES
OF THE SPHS
Each SPHS was analyzed according to their ability to comply with the
parameters proposed in the conceptual framework and shown in Table
12.
Table 12: Strengths and weaknesses of the SPHS
Parameter
Performance
yes
no
Increases equity in the access to and/or utilization of health services
Offsets social determinants that deteriorate health status and/or hinder the demand for
health care
Extends coverage of and/or increases access to technically appropriate interventions by
reducing or eliminating one or more causes of exclusion
The three parameters were broken down into smaller categories in order
to facilitate the analysis, as shown in tables 13, 14 and 15.
45
ANALYTICAL FRAMEWORK
4.2.3.1 EQUITY
Table 13: Performance of the SPHS: Equity
Category
Performance
yes
no
Increases equity in the access to health services
Increases equity in the utilization of health services
4.2.3.2 SOCIAL DETERMINANTS
The same criteria used to examine the effect of context on health status
and demand for health care (Table 8) were used to analyze whether the
SPHS was able to offset social determinants. The social determinants
selected were those widely recognized as having effects on health, as
discussed on the conceptual framework, section 3.2.2.1.
Table 14: Performance of the SPHS: social determinants
Category
Performance
yes
Offsets poverty by eliminating or reducing economic barrier
Fosters women’s social status
Fosters health rights through Right Charts, explicit guarantees, etc.
Offsets unemployment/informal labor by eliminating or reducing economic barrier
Offsets women’s lack of education by fostering demand for health care
4.2.3.3 COVERAGE AND ACCESS
To analyze whether the SPHS expands coverage of and increases access to technically appropriate health interventions, a matrix was built
based on the categories established in the conceptual framework, section
3.2.2.1. The matrix was divided into two components: coverage and access. Each component was measured by specific parameters: the number
of people covered by the scheme as a % of eligible population (coverage)
and the number of people with access to health goods or services provided by the scheme (access). Additionally, each component was broken
down into their corresponding subcomponents to help explain the reason
for the recorded increase, if any.
46
no
ANALYTICAL FRAMEWORK
Table 15: SPHS Performance: Increase coverage of and access to technically appropriate health
interventions by eliminating one or more causes of exclusion in health
SPHS
Category
yes
no
Increases coverage (rise in number of people covered as a % of eligible population)
Establishes a single guaranteed portfolio of entitlements with the same quality, content, and
delivery conditions for all socioeconomic groups as to avoid segmentation
Increases coordination/integration within the system so as to avoid fragmentation
Improves resource allocation and organization of health interventions by increasing number
and capabilities of human resources in previously underserved areas
Improves resource allocation and organization of health interventions by increasing the
amount of public spending allocated to the scheme
Public spending allocated to the scheme is progressive
Improves geographical distribution of the service delivery network and health infrastructure
by increasing number/amount of health facilities, equipment, medical devices, and drugs in
previously underserved areas
Increases information system’s coverage
Increases access by eliminating or reducing barriers to access (rise in number of people with
access to health goods or services provided by the scheme)
Eliminates/reduces geographic barrier
Eliminates/reduces economic barrier
Eliminates/reduces gender barrier
Eliminates/reduces employment status barrier
Improves access to drinkable water, sewerage, roads, and/or transportation
Improves refuse collection
47
ANALYTICAL FRAMEWORK
4.3
CONDUCTING THE ANALYSIS
A questionnaire was developed in order to conduct the analysis.
For each intervention, the following queries were made:
Table 16: Questionnaire
1.
What type of social protection scheme or intervention has been implemented?
2.
Is it universal or targeted?
3.
What type of targeting is used? (geographic-age-income-health condition)
4.
What is its scope? (national/sub-national/local)?
5.
How long has it been in place?
6.
Does it build on previous programs/interventions?
7.
Does it have explicit guarantees and/or benefits plan?
8.
Who is entitled to the right of coverage?
9.
Who are the beneficiaries among the country’s total MNCH population?
10. What goods and services does it cover?
11. Who is excluded?
12. How does it relate to the health system?
13. Who manages it (the public sector-private for profit-NGO-donor-international cooperation agency)?
14. Is it subject to regulation? Who regulates it?
15. Has public spending increased to finance the SPHS?
16. Has out-of pocket spending decreased within the eligible population since the SPHS started?
17. How is it financed (budgetary/extra budgetary source; taxes; affiliates contributions; donors, other)?
18. Are there any legal mechanisms that frame the operation of the social protection scheme?
19. Were there any changes in health outcomes after the implementation of the SPHS?
20. Were there any changes in health processes after the implementation of the SPHS?
21. Have there been any changes in access to health services after the implementation of the SPHS?
22. Has the social protection scheme brought more equity into the system?
23. Has the situation of exclusion in health improved with the implementation of the scheme?
48
ANALYTICAL FRAMEWORK
Health results indicators were used to guide the analysis and, in some
cases, as a measure of equity according to the conceptual framework in
3.2.b.1 I. Not all of the indicators listed below were used to analyze every
SPHS. Specific indicators were selected based on the availability of data
and on their relevance to the analysis of each SPHS.
Table 17: Set of indicators
Category
Indicator
Health
Results
-Maternal mortality ratio
-Infant Mortality Rate (IMR)
Health
Processes
-% of coverage institutional delivery
-% of women with 4 antenatal controls
-Number of antenatal controls
-% of women with one antenatal control before the 4th month of pregnancy
-% of women tested for syphilis during antenatal control, following specific standards
-% of women of indigenous origins or afro descendants using modern contraceptive methods
-Number of cases of neonatal tetanus diagnosed in newborns with less than 28 days
-% of children 12-23 months with complete immunization coverage (DPT, measles, polio,
BCG)
Exclusion
-% of women with access to institutional delivery
-% of women with complete antenatal control
-% of children with complete immunization coverage
-% coverage for Acute Respiratory Infections (ARI) for children under 5 years old
Equity
-% of women with access to institutional delivery by quintiles of income/ethnic origin/geographic location (urban-rural), type of provider
-Waiting time for women by quintiles income/ethnic origin/place of residence
-Waiting time for children under 5 years by quintile income/ethnic origin/gender/place
-Utilization of M-I services by income quintiles
-Gap between measles and BCG immunizations by quintiles of gender and income
4.4
INFORMATION SOURCES
a. Secondary sources: data from DHS (Demographic and Health Survey) , CDC (Center for Disease Control and Prevention), Ministries
of Health, National Statistics Systems, National Health Accounts,
PAHO/WHO, and household surveys were used.
b. Literature review: articles in peer reviewed journals as well as publications and reports from universities, international cooperation
agencies, development banks, and academic institutions in English,
Portuguese and Spanish, were used.
49
ANALYTICAL FRAMEWORK
c.
Internet search: documents from the institutions listed below:
•
•
•
•
•
•
•
•
•
•
•
•
4.5
Economic Commission for Latin America and the Caribbean
(ECLAC)
Global Watch
ILO
Inter-American Development Bank (IDB)
Partners for Health Reform Plus (PHRplus)
Panamerican Health Organization- PAHO
The World Bank
The Millennium Development Project
United Nations Children’s Fund (UNICEF)
United Nations Population Fund (UNPFA)
United States Agency for International Development (USAID)
World Health Organization - WHO
LIMITATIONS OF THE ANALYSIS
The variability of the data, as well as the multiplicity of SPHS in place,
the different stages of maturity of each scheme, and the wide range of
social determinants involved in each case made it very difficult to draw
conclusions on the direct effects of the SPHS on the health of MNCH
population. The method for analyzing SPHS used in this study yields information that allows for a general overview on how different SPHS have
performed, given their features and the general setting in which they were
implemented. However, neither association nor direct effect can be established between the performance of the SPHS and MNCH outcomes.
50
CASE STUDIES
5
5.1
CASE STUDIES
Mother & Child Universal Insurance (SUMI)
BOLIVIA
1 . CHARACTERIZATION OF THE SPHS
Bolivia’s health system, established in 1979, consists of a public health
sector, a social security system, and the private sector. In 1996, the Ministry of Health and Social Welfare launched the “To Live Better” Health
Plan, designed to strengthen the Bolivian health system and ensure universal access to individual, family, and community primary health care.
Three successive SPHS aimed at the mother and child population have
been implemented under the aegis of the Health Plan. They are the
National Maternal and Childhood Insurance (SNMN), the Basic Health
Insurance (SBS), and the Mother and Child Universal Insurance (SUMI).
Despite their names, they are not insurance schemes, but rather slightly
differing forms of free maternal and child care.
The SNMN was created in 1996 with the goal of reducing the number
of maternal deaths by 50% and halving the deaths of children under
five from pneumonia or diarrhea. The program’s creation was based
on the belief that reducing economic barriers to health would improve
access and increase utilization of health services. To this end, it focused
on providing services, free of charge, to children under five, as well as to
pregnant women. The SNMN was financed with municipal funds and resources from the National Treasury (Tesoro General de la Nación- TGN)
and from international cooperation. It originally covered 26 services,
51
CASE STUDIES
later expanded to 32 services, to be provided in public health facilities,
as well as those of the Social Security, and in the facilities of churches
and NGOs that had signed agreements with local municipalities. The
package included prenatal care; labor and delivery; postpartum care;
Caesarian-section; pre-eclampsia; eclampsia, and other obstetrical
emergencies; newborn care; neonatal asphyxia; pneumonia; sepsis, and
diarrhea, among others (UDAPE/UNICEF, 2006).
In 1998, the SNMN was replaced by the SBS, which increased the number of health interventions provided to 92, covering complications of the
newborn, sexually transmitted diseases, post-abortion care, and some
services directed at the general population and financed by national programs (malaria, tuberculosis and cholera). Besides health interventions,
the SBS included selected laboratory tests, transfer of patients referred
as a result of obstetric emergencies, and health personnel visits to rural communities without health facilities. The SBS not only expanded the
package of services; it also extended participation to all women of reproductive age, as well as including Social Security and non-profit providers
in its provision.
Although the SUMI, created in 2003, retained the goal of reducing maternal and child mortality by increasing health services utilization through
the elimination of economic barriers, it also introduced substantial
changes in the system. It included higher complexity care for mothers
and children in the provided benefits, thus distinguishing itself from previous programs which primarily focused on basic care. In order to provide
such high-level care, the program extended its benefits package to all
institutionalized health services and made it available to women, through
pregnancy and up to six months after childbirth, and to children under 5
years old. This group received care in all three sub-systems: the public
system, Social Security, and certain private establishments assigned as
providers, all of them organized into municipal health networks. But the
SUMI also restricted coverage, removing the general population and reproductive age women.14
14. The government has recently sought to extend coverage under the free insurance, first to all Bolivians over 60 (Seguro de
Vejez) secondly to Bolivians under 21, and finally to all citizens (Seguro Universal de Salud). But legislative ratification of
the universal insurance, and the implementation of the old-age insurance, has been blocked by disagreements between central
and municipal governments over funding for the programs.
52
CASE STUDIES
Table 18: The evolution of the mother and child universal insurance in Bolivia
SNMN
SBS
SUMI
Target population
Pregnant women and
children under 5 years
Pregnant women, children
under 5 years and general
population for specific interventions
Pregnant women until 6 months
after childbirth and children
under 5 years
Package
(risks covered)
32 interventions corresponding to the first and
second levels of care
92 interventions corresponding to the first and
second levels of care
Comprehensive, with few exceptions. Includes complex care and
dental care
Financing
2.7% of central tax transfers to municipalities
(3.2% of 85% of “coparticipation” funds)
10% of central tax transfers plus
5.4% of central tax transfers
10% of the National Dialogue
to municipalities
Account1 for the National Redis(6.4% of 85% of “co-partribution Fund (Fondo Solidario
ticipation” funds)
Nacional, or FSN)
Distribution of
funds
Per capita distribution to
municipalities
Per capita distribution to
municipalities
Payment Mechanism
Fee-for-service reimburse- Fee-for-service reimbursement; Fees set centrally
ment; Fees set centrally
Management
Municipality reimburses
health facilities
Municipality pays health
district, which consolidates
information from facilities
Municipality pays Management
of health network after approval
by Local Health Directories
Reimbursement
fees
Based on variable costs
(drugs and other inputs)
+ incentives for deliveries
and other priority services
Based on variable costs
(drugs and other inputs) +
incentives for deliveries and
other priority services
Based on variable costs and estimated frequency of cases; differentiated by level of complexity
of facilities
Use of excess
funds
Forbidden; specific
one-time exceptions were
granted
Forbidden; specific onetime exceptions were
granted
Regular use granted for health
investments
Per capita distribution of central
tax transfers plus demand-based
access to FSN to cover deficits
Fee-for-service reimbursement;
Fees set centrally
1. The National Dialogue Account was established in Bolivia as a frame of the HIPC iniciative aimed at
alleviating the burden of the external debt.
SOURCE: The World Bank, 2003
The SUMI also seeks:
i) to strengthen the processes of decentralization and the participation of
civic organizations in health management through the implementation of
Local Health Directories (DILOS) and social networks
ii) to strengthen municipal participation in the financing of drugs, supplies, and laboratory tests as well as the Municipal government’s responsibility for paying participating health providers for drugs, supplies, and
hospitalizations,
53
CASE STUDIES
iii) to provide incentives to providers through a mechanism based on feefor-service payments.
The SUMI not only doubled the resources earmarked at the municipal
level (to 10% of the central tax transfers distributed to the municipalities
on a per capita basis), but also created a National Redistribution Fund,
financed with 10% of the Special National Dialogue Account. These additional funds are not distributed to municipalities on a per capita basis
but are available for municipalities whose own resources are insufficient
to cover needs. Therefore, the financial resources for the program derive
from three sources:
•
•
•
National Treasury (TGN): finances the human resources of the
public health subsystem, while Social Security or other facilities
enlisted in the SPHS cover human resources with their own funds.
Taxes: a percentage of co-participation funds (7% in 2003, 8% in
2004, and 10% in 2005) from each municipality is used for benefit payments.
National Redistribution Fund
The estimated beneficiary population by 2004 was 1,600,000 - around
74% of the target population. 1,279,000 children under 5 years of age
and 328,000 women (either pregnant or within 6 months of pregnancy)
were covered.
Table 19:. SUMI’s main features
Feature
54
Category
Type
Free maternal and child health care
Mode of financing
Publicly funded
Source of funds
General taxes
Other revenues: extra budgetary source (HIPC II)
Risk pooling arrangement
Income-based
Management and management level
National/Sub-national/Local MoH
Local government
Degree of selectivity
Targeted: Pregnant women until 6 month after childbirth and
children under five years old
Who is entitled to coverage
Individual
Condition for access
Specific attribute: age/proof of childbirth/proof of pregnancy
Extent of risk pooling
Small pool
Explicit portfolio?
Not explicit
Degree of coverage
Complementary
Provision
Mainly public
CASE STUDIES
2 . CHARACTERIZATION OF THE GENERAL SETTING IN
WHICH THE SPHS IS IMPLEMENTED
Basic Information - Bolivia is a low income country located in the Andean
Region of South America. It has a population of approximately 9.1 million, with 37% living in rural areas, (as of 2002). More than 80% of the
population is under 50 years of age, 13% is under five years old and 48%
is of childbearing age (15-49 years old) (UDAPE-PAHO/WHO, 2004).
Bolivia is a republic, with an elected president and bicameral legislature.
Evo Morales, the current president and Bolivia’s first chief of state from
an indigenous background, took office in January 2006. He has made
social protection in health a priority, pushing to expand the SUMI into a
Universal Health insurance.
Ethnicity - Bolivia is a multiethnic country, with 36 different indigenous
groups making up 52.3% of the total population. The main indigenous
groups are the Aymara (30%) and the Quechua (30%), and many members of these groups do not speak Spanish fluently. The indigenous population suffers from political and social exclusion, and the poverty rate
among the indigenous population (78%) is much higher than among
those of European descent (less than 50%) (UDAPE-PAHO/WHO, 2004).
According to 2002 figures, 91.25% of the indigenous population is covered neither by Social Security nor by a private health insurance (UDAPEPAHO/WHO, 2004). Deep conflicts over the distribution of power, land,
and wealth between the descendants of Europeans and the indigenous
population prevail in Bolivian society, posing a threat to the country’s
governance and hampering social cohesion (UDAPE-PAHO/WHO,
2004; Pavez Wellmann, 2005).
Economic Situation - The majority of the population (64.6%) lives in
poverty, making Bolivia one of the poorest countries in Latin America.
This situation is especially severe in rural areas and among indigenous
groups. Poverty is accompanied by high levels of income disparity, with
the average income of the richest percentile 15 times higher than that of
the poorest 10% of the population. Unemployment and informality are
high, with 50% of the population unemployed and 64.1% of workers
belonging to the informal sector. Women usually suffer worse working
conditions and have lower salaries and lower educational levels than
men. In 1999, 16.4% of the population was illiterate (UDAPE-PAHO/
WHO, 2004), and in 1997 the National Survey of Employment showed
that illiteracy rates were nearly three times as high among women over
15 as among men of the same age (PAHO/WHO, 2002).
Health - Life expectancy at birth in 2003 was 65 years old; the total
fertility rate remains high compared to other countries in the region, but
decreased from 4.8 in 1993 to 3.8 in 2003. The incidence of exclusion
55
CASE STUDIES
from health care among the general population is 77%, with poverty
and women’s illiteracy its main causes (PAHO/WHO-UDAPE, 2004). According to the World Bank, the barriers to access that result from cultural
diversity remain some of “the greatest challenges to improved health
among the poor in Bolivia” (World Bank, 2004).
Bolivia’s health services network consists of 40 general hospitals, 30 specialized hospitals, 149 basic hospitals, 986 health centers, and 1,408
health posts. Of these facilities, 1,995 belong to the public sector, 197
to Social Security, 254 to NGOs, 101 to the Church, and 66 to the private sector. Households remain an important source of financing for the
health sector, contributing to 30% of total health expenditure. Between
1999 and 2001, health care costs consumed more than 10% of monthly
expenditure in about 10% of households, and more than 50% of monthly
expenditure in 1.2% of households. Seventy-five percent of household
health expenditures are on the purchase of pharmaceuticals in drugstores, representing 20% of national health expenditures (MECOVI survey, 2000).
Table 20: Bolivia’s general situation
Contextual factor
Health status
Deteriorates
Poverty Rate
X
Improves
Demand for health
care
Hinders
X
Education level
X
X
No. of Rural dwelling/remote settlements
X
X
Access to water/sanitation/electricity
X
Government’s institutional strength/fragility
X
Country’s governance
X
Unemployment Rate
X
X
Labor informality
X
X
3 . ANALYSIS OF THE PERFORMANCE OF THE SPHS
NOTE: The core goals of the three SPHS, as well as their strategies for
implementation, were very similar. Therefore, because they succeeded
each other without interruption, and also because little data for the post2003 period exists, the analysis will deal with the combined impact of all
three, using the blanket term SUMI for the sake of convenience.
56
Promotes
CASE STUDIES
a). Has it increased equity in the access to/utilization of
health services?
Utilization of the formal maternal and child health care services covered
by the program increased with the implementation of the SUMI. Between
1994 and 2003, the percentage of mothers who utilized health sevicies through the mother and child insurance grew from 3.6% to 53.4%,
with by far the highest rate of growth taking place in the lowest income
quintile (UDAPE/UNICEF, 2006). Moreover, between 1994 and 2003
this quintile, which contains the largest number of those excluded from
health, showed the greatest increase in the utilization of skilled birth assistance, from 5.3% to 21.1% (UDAPE/UNICEF, 2006). The drop in mortality rates during the period (discussed below in section ‘e’) may be
related to this increase in coverage.
However, two concerns remain: (i) in recent years, the rate of increase
in coverage has been tapering off; and (ii) the equity gap between the
urban and rural, the indigenous and non-indigenous, and the rich and
the poor remains high. According to data from the Ministry of Health, in
the year 2003 the coverage of institutional deliveries was 55% in the richest Municipal districts, as compared with 41% in the poorest ones. The
MECOVI survey found that in 2001 20% of the poorest quintile had access to skilled birth attendance, compared to 89% of the richest quintile.
Other studies found that, controlling for income and other characteristics, the probability of having institutional attendance at childbirth is 29%
higher if the family lives in an urban area rather than in a rural area, and
17% lower if the head of household is indigenous (World Bank, 2003).
b). Has it offset social determinants that damage health
and/or hinder the demand for health care?
Several social determinants act as hindering factors in Bolivia. The most
important are poverty, discrimination related to ethnic background, and
women’s low status in society. The SUMI has helped offset high rates of
poverty and unemployment/informal labor, increasing the demand for
heath care among people in the lowest income quintiles by eliminating
the economic barrier. It seems to have not yet reached rural areas and
isolated communities, nor has it significantly encouraged women to demand health services. UDAPE found that the most frequent users of public health services were urban mothers with a relatively high income and
educational level. But use of public services among mothers with no education increased nearly 300% between 1994 and 2003, while rising only
2% among mothers with a post-secondary education (UDAPE/UNICEF,
2006). To date the SUMI has not issued mechanisms to enforce the right
to health. Moreover, discrimination by indigenous origin continues to be
57
CASE STUDIES
an issue in the provision of health care (PAHO/WHO-UDAPE, 2004).
The failure of the SUMI to adequately cover the indigenous majority will
likely place severe limitations on its overall effectiveness.
Table 21: SUMI’s performance: social determinants
Category
Performance
yes
Offsets poverty by eliminating or reducing economic barrier
Fosters women’s social status
X
Fosters health rights through Right Charts, explicit guarantees, etc.
X
Offsets unemployment/informal labor by eliminating or reducing economic barrier
X
Offsets women’s lack of education, fostering the demand for health care
X
c). Has it increased access to and coverage of technically
appropriate health interventions by eliminating one or
more sources of exclusion from health care?
Results to date suggest that the SUMI has been successful in removing the
economic barrier to access health services, as evidenced by the observed
increase in coverage of priority services for people in the lower income
quintiles. However it has not so far addressed other barriers to access
that are important causes of exclusion in health in the country, such as
cultural or geographic barriers.
According to the ENDSA (Encuesta Nacional de Demografía y Salud)
survey, the nation-wide use of skilled birth assistance (doctor, nurse) has
increased remarkably, from 27% in 1995 to 55.3% in 2003.15 The highest rate of increase was observed between 1998 and 2000, the period
during which the SBS was first implemented. Utilization of services also
rose in the treatment of pneumonia in children under five. According to
USAID’s Partners for Health Reformplus (PHRplus), at least part of this
increase can be attributed to SUMI because it exceeds the rate of increase in the utilization of non-covered services and services delivered
by non-participating providers. In the case of the 4th prenatal control, the
national average increased from 26% coverage in 1996 to 40% in 2004
(UDAPE/UNICEF, 2006).
15. Other sources such as the demographic and health surveys estimate that the use of skilled birth assistance (doctor, nurse)
increased from 43.2 % in 1994 to 59.3% in 1998. UDAPE gives the figures of 29% in 1989 and 53.4% in 2003, with the
greatest increase occurring between 1998 and 2003 (UDAPE/UNICEF, 2006).
58
no
X
CASE STUDIES
Available data suggest that public health spending allocated to the SUMI
is progressive because it has mainly benefited those in the lowest income
quintiles. It is noteworthy that the financial resources allocated to the
scheme have steadily increased over the years (for example, central tax
transfers to municipalities to deliver the scheme went from 2.7% in 1996
to 10% in 2003), although total public expenditure on health decreased
by 3.1% from 1998-2002. The country’s increase in total expenditure on
health, from 5% of GDP (Gross Demographic Product) in 2001 to 7% in
2002, was due to an increase in out-of-pocket expenditure, which grew
by 7.1% during that time period.
The SUMI has had little impact on the supply of health services, which are
unequally distributed in the country. Misallocation of services produces
important access problems, due to long distances between health facilities and households and low installed capacity in rural areas. Although
analysis of the SBS’ outcomes (SBS, 1998-2002) shows that it improved
health financing, reinforced national health priorities, promoted demand
for primary health services, and empowered users, low coverage is still a
problem in the public sub-sector, with 30% of the population not covered
(PAHO/WHO, 2001(c)). Many problems currently persist in access to
care due to the low quality of care, especially the technical aspects of
the treatment of obstetric emergencies and the lack of cultural adequacy
in the provision of health services. The increased demand for care may
have put even more stress on already strained human and technological
resources.
The SUMI, by establishing explicit relationships and coordination mechanisms between different territorial and managerial levels within the public
subsystem, has helped to overcome fragmentation in the area of maternal
and child interventions. It has not helped to reduce segmentation, since
its goal is not the equalization of quality, content, and delivery conditions
of the health services offered to different socioeconomic groups.
59
CASE STUDIES
Table 22: SUMI’s performance: Coverage and access
Category
Increases coverage (rise in number of people covered as a % of eligible population)
SPHS
yes
X
Establishes a single guaranteed portfolio of entitlements with the same quality, content, and
delivery conditions for all socioeconomic groups so as to avoid segmentation
Increases coordination/integration within the system so as to avoid fragmentation
X
X
Improves resource allocation and organization of health interventions by increasing the number
and capabilities of human resources in previously underserved areas
X
Improves resource allocation and organization of health interventions by increasing the amount
of public spending allocated to the scheme
X
Public spending allocated to the scheme is progressive
X
Improves geographical distribution of the service delivery network and health infrastructure by
increasing the number/amount of health facilities, equipment, medical devices, and drugs in
previously underserved areas
X
Increases information system’s coverage
X
Increases access (rise in number of people who access goods/services provided)
X
Eliminates/reduces geographic barrier
Eliminates/reduces economic barrier
X
X
Eliminates/reduces gender barrier
Eliminates/reduces employment status barrier
X
X
Improves access to drinkable water, sewerage, roads, and/or transportation
X
Improves refuse collection
X
d). Have health outcomes improved?
Maternal Mortality Ratio, Infant Mortality Rate, and Neonatal Mortality Rate decreased over the period from 1998 to 2003. Infant mortality
dropped from 75 to 54 per thousand, child mortality decreased from
43 to 23 per thousand, and maternal mortality fell from 390 to 229 per
100,000 births (UDAPE/UNICEF, 2006). But these gains were not always
equally distributed. While the impact of the scheme on the risk of infant
mortality in urban areas was significant, it was nearly nil in rural areas,
with the reverse being true for the risk of under five mortality (UDAPE/
UNICEF, 2006). These mixed results - significant impact on the risk of
infant death in urban areas and under five death in rural areas - make
it difficult to draw a causal connection between the implementation of
the schemes and reduced infant mortality. But it can be argued that the
60
no
CASE STUDIES
overall downward trend in maternal and neonatal mortality is linked to
the increased frequency of institutional delivery among the lowest income
quintiles - which characteristically exhibit the highest neonatal and maternal mortality. This rise in the coverage of institutional births is due to the
lowering of economic barriers achieved by the three consecutive SPHS.
In spite of the important achievements in the reduction of maternal and
infant mortality rates in recent years, however, those rates are still high
compared to those of other countries in the Region.
Graph N. 2
U n d e r-5 M o rta lity in B o liv ia , 1 9 8 9 -2 0 0 3
160
140
120
100
Deaths Ages 1-5
80
Deaths Age 1 and
Under
60
40
20
0
1989
1994
1998
2003
Source: UDAPE/UNICEF, 2006
Table 23: SUMI’s performance
Goal
Performance
Increases equity in the access to and/or utilization of
health services
It has increased equity in the access to health
services. Important gaps remain
Offsets social determinants that hinder the demand for
health care and/or deteriorate health status
It has helped to offset poverty
Increases access to and coverage of technically appropriate health services by reducing or eliminating one or
more causes of exclusion
It has increased access of previously excluded
groups by reducing the economic barrier. It has
increased coverage of technically appropiate
health services
61
CASE STUDIES
5.2
The Family Health Program (Programa
Saúde da Família, PSF) BRAZIL
1 . CHARACTERIZATION OF THE SPHS
The Family Health Program (PSF) is a set of community-oriented programs
providing a broad array of primary health services. As an instrument for
implementing interventions developed by the Ministry of Health, the PSF
is considered the main government effort to improve primary health care
in Brazil. Several smaller health care programs are implemented within
the broad framework of the PSF. These include the Child Health Program
(Saúde da Criança); the Women’s Health Program (Saúde da Mulher);
the National Pact for the Reduction of Maternal and Infant Mortality (Pacto Nacional pela Redução da Mortalidade Materna e Neonatal), with
the goal of reducing 2004 maternal and infant mortality rates by 75%
by the year 2015; and the Antenatal and Birth Humanization Program
(Programa de Humanização do Pré-natal e Nascimento), which aims to
improve access to, and coverage and quality of antenatal, delivery, and
postpartum care, and care for newborns.
The PSF was created in 1994 with the goal of providing preventive health
care to a larger segment of the population by i) reaching the municipalities not covered by Primary Heath Care facilities; ii) transforming the
health care model from a passive to a more active strategy that involves
the community; and iii) providing high quality primary health care, especially to the poor. By 1998, the PSF had become the center of a model
of care based on the principles of decentralization, equity, and shared
responsibility, one that prioritizes population groups with the highest risks
of morbidity and mortality (Ministry of Health, Brazil, 2006).
Health care is delivered by a team composed of at least one family doctor, one nurse, and five or six community agents, who live in the community and are trained to carry out health promotion activities. Each team
is assigned to a specific territorial unit and is responsible for enrolling
and monitoring the health status of approximately 1,000 families living
in the area, providing primary care and making referrals to other levels
of care as required. The make-up of the PSF team was designed to foster
a sense of mutual responsibility towards health by encouraging close
ties with the population it serves. Physicians and nurses typically deliver
services at health facilities placed within the community, while community
agents provide health promotion and education services during household visits.
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CASE STUDIES
The services included in the PSF contain an assortment of required interventions, as well as guidelines for how they should be implemented. The
PSF teams assign priority to specific actions according to the profile of
each municipality. In 2005, the Ministry of Health released the “Agenda
for Integral Child Health and Infant Mortality Rate Reduction” (Agenda
de Compromissos para a Saúde Integral da Criança e Redução da Mortalidade Infantil), which establishes guidelines for the application of maternal and child health interventions in the context of the PSF. According
to the Agenda, the minimum set of interventions that must be available
to mothers and newborns includes:
•
•
•
•
•
Prenatal care
Institutional delivery (and home delivery in selected municipalities in
the North, Northeast and Mid-West regions)
Postpartum care
Care for maternal emergencies, with access to beds in Intensive
Care Units (ICU)
Immediate care for newborns in the delivery room, with access to
hospitalization and Intensive Care Units
The PSF is the basis for the “Agreed Integrated Programming” system,
which organizes referrals, helping to avoid fragmentation within the
system (Ministry of Health, Brazil, 2006). It is also the center of a unified health information system: both the Basic Health Care Information
System (SIAB) and the National Health Card have been implemented
through the PSF (Ministry of Health, Brazil, 2006).
Financing for the PSF comes primarily from transfers from the federal government on a per capita basis. The Ministry of Health offers incentives to
municipalities that attain coverage of more than 70% of the population,
paying around US$20,000 per team per year compared to US$10,000
for those municipalities with coverage below 5%. Considerable investments have been made in the PSF to date.
63
CASE STUDIES
Table 24: PSF’s main features
Feature
Category
Type
Free primary health care provision scheme
Mode of financing
Publicly funded
Source of funds
General taxes
Risk pooling arrangement
Community-rated
Management and management level
National/Sub-national/Local MoH
Local governments
Degree of selectivity
Universal
Who is entitled to coverage
Family
Condition for access
Place of residence
Extent of risk pooling
Large pool
Explicit portfolio?
Not explicit
Degree of coverage
Comprehensive
Provision
Public
2 . CHARACTERIZATION OF THE GENERAL SETTING IN
WHICH THE SPHS IS IMPLEMENTED
Basic Information - Brazil is an upper-middle income country located in
Eastern South America, bordering the Atlantic Ocean. It is the largest
country in South America and shares common boundaries with every
South American country except Chile and Ecuador. Brazil conducted a
census in August 2000, which reported a population of 169,799,170,
although it is now estimated at 189 million (Instituto Brasileiro de Geografía e Estatística (IBGE), 2004; 2007).
Economy – Brazil has the worst income inequality in the region of the
Americas and one of the greatest levels of inequality in the world. A recent
World Bank study shows that the richest quintile’s share of the country’s
total income was 67.5%, while the poorest quintile’s share was only 2.1%
(World Bank 2000). According to IBGE, 57.7 million Brazilians (35%)
were living under the poverty line in 2003, 22 million of whom qualified
as extremely poor.16 The national GDP per capita (about US$9,000 PPP,
according to the IMF) conceals drastic regional inequalities. The highest
poverty rates are found in the North and Northeast regions, where 13.8
million people are extremely poor. Extreme poverty is highest in small
Municipalities under 50,000 inhabitants, where public services are very
scarce (United Nations Fund for Population Activities- UNFPA, 2005).
16.
64
Poverty is defined as the percentage of the population that has a per capita income of less than half of the monthly minimum
wage.
CASE STUDIES
There was considerable progress in women’s development in the last
decade: female illiteracy declined by a third, although the illiteracy rate
is still high. The adult literacy rate (% ages 15 and above) was 88.4 as of
2003 (UNDP-HDR 2005).
Unemployment reached 11.5% in 2004. According to a survey conducted by IBGE in 2004, there were 2.1 million people unemployed in the six
major metropolitan areas of Brazil. The informal sector has been growing
significantly, accounting for almost 25% of the total working population
of the country.17
Health - According to the WHO (2005), life expectancy in Brazil in 2003
was 69 years and the under-five mortality rate in 2000 was 23 per 1,000
live births; according to the World Bank, 2005, the infant mortality rate
in 2002 was 20 per 1,000 live births, but Macinko et al. give the slightly
higher rate of 28.9 per 1,000. The Maternal Mortality Ratio reported
by the country in 2000 was around 50 per 100,000 live births, but the
WHO gave a figure for the same year of 260 deaths per 100,000 live
births (WHO, 2005). Child deaths from diarrhea declined by two thirds
between 1990 and 2002 and deaths from acute respiratory infections
were halved during the same period (Macinko et al., 2006).
In 2000 74% of the total population had access to drinkable water and
64% had access to sanitation. But these figures contain stark differences
between urban and rural areas: 95% of the urban population had access to drinkable water, compared to only 53% of rural population. The
gap was similar for sanitation: 84% of the urban population and 43%
of the rural population benefited from proper sanitation (WHO/UNICEF,
2001).
The majority of the Brazilian population -83%- is concentrated in urban
areas, with most of the poor living in shantytowns, the well-known “favelas” (UNDP-HDR 2005). Despite the trend towards urbanization, reaching isolated communities still poses a challenge due to Brazil’s territorial
dimensions and geography.
The 1988 Brazilian Constitution recognizes health and education as universal rights. The Constitution also determines that the Brazilian State is
responsible for assuring that every citizen has equal and free access to
health care. Health care in Brazil is implemented through a combination
of two subsystems: the public and the private. The public subsystem covers 76% of the population through the Unified Health System (Sistema
Único de Saúde, SUS) implemented in 1988 and comprised of public
and private providers. The SUS offers free and comprehensive health
17.
Online article: http://www.brazilmag.com/content/view/2480/49/
65
CASE STUDIES
care for anyone, independent of contribution or affiliation. The private
subsystem covers 25% of the population, which may also access the public subsystem (PAHO/WHO, 2005). In a country with such huge income
disparities, the SUS has been an important mechanism for equalizing
access to health services.
One of the goals of the Unified Health System was universal access to
health care, especially among the most vulnerable populations. To that
end a new model of primary health care was adopted, based on the
principles of universality, equity, and integrality of health interventions. In
1991, the Ministry of Health implemented the Community Health Agents
Program (Programa de Agentes Comunitários de Saúde, PACS) to address high maternal and infant mortality rates, especially in the Northeast
region of Brazil. The PACS was the forerunner of the PSF, with its emphasis in the family and focus on demand (Brazilian Ministry of Health,
2003). Several second generation programs followed, including the PSF,
the Popular Drugstore Program (Programa Farmácia Popular), which provided access to 40 essential medicines, and the National Pact for the
Reduction of Maternal and Neonatal Mortality.
McGuire points out (McGuire, 2001) that, despite having the fastest
per capita GDP growth in Latin America from 1960 to 1995, Brazil
underperformed at reducing infant mortality. According to this author,
socioeconomic disadvantage was not the main cause of Brazil’s slow
improvement in this area, but rather the neglect of primary health care for
the poor. The inauguration of President Fernando Henrique Cardoso in
1995 launched a period of unprecedented emphasis on primary health
care through the creation of PSF and the other programs mentioned
above. According to the then Health Minister Jose Serra (Serra, 2001),
federal spending on health at the time grew about 30% in real terms,
while the proportion of total health expenditure spent on primary health
care rose from 17% to 25%. General government expenditure on health
was 45.9% of total expenditure on health in 2002, while out-of pocket
expenditure on health was 34.6% of the total expenditure on health in the
same year (UNDP-HDR 2005).
66
CASE STUDIES
Table 25: Brazil’s general situation
Contextual factor
Deteriorates
Poverty
Demand for health
care
Health status
Improves
X
Hinders
Promotes
X
Education level
X
X
No. of Rural dwellings/remote settlements
X
X
Access to water/sanitation/electricity
X
Government’s institutional strength/fragility
X
X
Country’s governance
X
X
Unemployment Rate
X
X
Level of Labor informality
X
X
3 . ANALYSIS OF THE PERFORMANCE OF THE SPHS
a). Has it increased equity in the access to and/or utilization of health services?
The PSF has so far played an important role in increasing access to and
utilization of health services among the formerly excluded population.
From 1987 to 1997, according to national health surveys, the proportion of the population with access to basic care rose from 73% to 95%,
and the proportion of infants routinely vaccinated increased from 53% to
79% (Brazil’s Ministry of Health, 2001). From 1986 to 1996, the proportion of women receiving prenatal care from trained personnel rose from
74% to 85% and institutional births increased from 80% to 91%. Because
better-off Brazilians already had high coverage before the implementation of the PSF, it is reasonable to assume that a fair proportion of the
improvement took place among the population previously underserved
(McGuire, 2001).
In the poorer municipalities (those with median per capita family income
lower than one minimum salary) PSF’s coverage has expanded from
10.75% in 1998 to 58.49% of the population in 2004, while in the richest municipalities (those with median per capita family income equal or
higher than two minimum salaries) coverage expanded only from 4.27%
to 24.89% of the population in the same period of time. Despite this high
coverage, the proportion of mothers not receiving antenatal care was
higher (21%) in the poorest quintile than in the wealthiest (4%). Similarly,
inadequate antenatal care was more common among the poorest (50%
vs. 19%) (Barros et at, 2005). According to Ministry of Health data, the
program has increased overall coverage in the country from 15% of
the population in 1994 to 42.7% in 2005 (Ministry of Health, Brazil,
2006).
67
CASE STUDIES
b). Has it offset social determinants that damage health
and/or hinder the demand for health care?
The PSF has made some strides towards overcoming the ill-effects of poverty and informal employment on health, but is far from achieving complete success. Although the demand for health services has increased
since the program was launched, the finding that inadequate antenatal
care was more common among the poorest seems to indicate that the
program needs to improve quality of care, not just coverage (Barros et
al., 2005). A study performed by Barros et al. in Sergipe found that,
while there was no difference in demand for health care between income
quintiles, those in the lowest quintiles were far more likely to receive inadequate antenatal care, with nearly 50% of those in the lower two quintiles
receiving inadequate care, as opposed to less than 20% in the highest
income quintile (Barros et al., 2004).
The PSF also helps to foster rights in at least some areas of health by
including a specific guarantee of rights: the National Sexual and Reproductive Rights Policy was launched in 2005, and includes family planning
programs for the period 2005-2007, aimed at guaranteeing the sexual
and reproductive health rights of both adults and adolescents (PAHO/
WHO, 2005).
Table 26: PSF’s performance: social determinants
Category
Offsets poverty by eliminating or reducing economic barrier
Performance
yes
X
X
Fosters women’s social status
68
no
Fosters health rights through Right Charts, explicit guarantees, etc.
X
Offsets unemployment/informal labor by eliminating or reducing economic barrier
X
Offsets women’s lack of education, fostering demand for health care
X
CASE STUDIES
c). Has it increased access to or coverage of technically
appropriate health interventions by eliminating
a source of exclusion from health care?
As a program focused on strengthening health care delivery, the PSF has
contributed to expanding the health system’s infrastructure to locations
not previously covered, especially the poorer ones. In February 2005,
the PSF covered 83% of the municipalities in Brazil, through 21,391
primary health teams. (PAHO/WHO, 2005). The program has attained
the highest coverage in the Northeast - the poorest geographic region
- with 49.8%t of the population covered by the PSF. The PSF also shows
a pattern of coverage expansion that has favored the less populated municipalities, clearly seeking to eliminate the geographic barrier. According to the Ministry of Health, by 2004 the program covered 65.29% of
the population living in municipalities with less than 20,000 inhabitants,
but only 27.5% of the population living in municipalities with 80,000 or
more inhabitants (Ministry of Health, Brazil, 2006).
The PSF has attempted to avoid segmentation by establishing a set of
health care services that must be available to all mothers and newborns
with the same quality, content, and delivery conditions regardless of socioeconomic status. However, problems related to waiting times, hours
of operation, and limitations in access to specialized services as well as
laboratory and imaging services persist, prompting those who can pay
to walk away from the program (Macinko et al., 2005). According to a
study carried out by Barros et al. in Porto Alegre, the PSF’s higher coverage among the poor was a result of self-exclusion on the part of the
better-off due to problems with quality (Barros et al. 2005).
Results to date suggest that the PSF has been successful in removing
economic barriers to access to primary health care services, as evinced
by the observed increase in services utilization among the poor population. Although public spending in health has gone through ups and
downs along with the economic crises that have rocked the country, it
increased from 2.76% of GDP in 1990 to 3.6% of GDP in 2002 (World
Bank, 1995; UNDP, 2005). The amount of public spending allocated to
the PSF accounts for an important share of this increase. Federal transfers account for only about 40% of the costs of the program, so local
resources are crucial to its existence (McGuire, 2001). Given that the
Program’s resource allocation has favored the poorest municipalities, it
can be assumed that the public spending allocated to the program has
been progressive. However, households remain an important source of
financing for the sector, contributing to 34.6% of the total expenditure
on health.
69
CASE STUDIES
Table 27: PSF: Coverage and access
SPHS
yes
no
Category
Increases coverage (rise in number of people covered as a % of eligible population)
X
Establishes a single guaranteed portfolio of entitlements with the same quality, content, and
delivery conditions for all socioeconomic groups so as to avoid segmentation
X
Increases coordination/integration within the system so as to avoid fragmentation
X
Improves resource allocation and organization of health interventions by increasing number
and capabilities of human resources in previously underserved areas
X
Improves resource allocation and organization of health interventions by increasing the
amount of public spending allocated to the scheme
X
Public spending allocated to the scheme is progressive
X
Improves geographical distribution of the service delivery network and health infrastructure
by increasing number/amount of health facilities, equipment, medical devices, and drugs in
previously underserved areas
X
Increases information system’s coverage
X
Increases access (number of people who access health goods or services provided by the
scheme)
X
Eliminates/reduces geographic barrier
X
Eliminates/reduces economic barrier
X
Eliminates/reduces gender barrier
Eliminates/reduces employment status barrier
X
X
Improves access to drinkable water, sewerage, roads, and/or transportation
X
Improves refuse collection
X
d). Have health outcomes improved?
According to a study carried out by Macinko, Guanais, and Marinho de
Souza (2003), the PSF has contributed to the decline of infant mortality
in Brazil. From 1990-2002 the Infant Mortality Rate (IMR) declined from
49.7 to 28.9 per 1,000 live births. During the same period, average PSF
coverage increased from 0 to 36%. A 10% increase in PSF coverage
was associated with a 4.5% decrease in IMR, controlling for all other
health determinants. The results indicate that the PSF may reduce IMR at
least partly through the reduction of diarrhea deaths. The PSF has also
been associated with increased immunization rates, breast-feeding rates,
and better maternal management of diarrhea and respiratory infections
(Emond et al. 2002).
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CASE STUDIES
Although the Maternal Mortality ratio declined from 57.1 per 100,000
live births in 1999 to 51.6 in 2006 according to data provided by the
Ministry of Health, maternal mortality is still high in Brazil when compared
to other LAC countries and very high compared to the average figure for
upper middle-income countries (Ministry of Health, Brazil, 2005). This is
especially true when using the WHO figure of 260 maternal deaths for
every 100,000 live births, placing Brazil far above the South American
average of 165 and behind only Bolivia and Peru (WHO, 2007). Further
efforts must be made to improve maternal health care through the PSF.
According to the Brazilian Ministry of Health, the hospitalization rate in
the areas covered by the PSF decreased from 52.3 per 10,000 inhabitants to 37.7 per 10,000 inhabitants in the last three years (Brazil’s MoH,
2005) which indicates that the program has been successful in dealing
with health problems at the primary care level.
Table 28: PSF’s performance
Goal
Performance
Increase equity in the access to and/or utilization of
health services
It has increased equity in access to and utilization of
health services provided by the program
Offset social determinants that hinder demand for
health care and/or hamper health status
The program has helped to offset poverty and mother’s
lack of education
Increase access to and coverage of technically
appropriate health interventions by reducing or
eliminating at least one cause of exclusion in health
It has increased access by reducing the economic and
geographic barriers. It has increased coverage (human
resources, health facilities) in previously underserved
areas
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CASE STUDIES
5.3
MCHSHPP: An integral and long term state
policy focused on MCH social health
protection -CHILE
1 . CHARACTERIZATION OF THE SPHS
Chile has a long history of public concern for the health of mothers and
children. The state’s efforts in this field began in 1890, with the creation
of the agency of public hygiene and sanitation. In 1924, with the establishment of social security, the state assumed an active role in providing
health care to workers and their families. The Maternity Care and Supplementary Food Program for workers’ wives and children up to two years
of age started in 1938. As early as 1942, a free milk program extended
its coverage to uninsured and indigent children and pregnant women
and linked provision of benefits to health check ups. The National Health
Service, created in 1952, unified the health system under a single public
office with one goal: to protect the health of mothers and children. To
accomplish this end, three programs were created: the Maternal and
Perinatal Program (Programa de salud maternal y perinatal); the Children
and Teenagers’ Health Program (Programa de salud infantil y adolescente); and the National Supplementary Food Program (Programa Nacional de Alimentación Complementaria, PNAC). These programs are
still standing today (Idiart 2004).
During Salvador Allende’s socialist government (1970-1973), the
PNAC was extended to all primary school children and to all pregnant
women, regardless of their employment or income condition. The existing
programs were improved; complementary nutritional schemes were
applied to malnourished children; and antenatal care was emphasized.
Under military rule (1973-1989), in spite of severe public expenditure
reductions, the mother and child health programs became, again, the
first priority. It is noteworthy that infant mortality rate plunged from 65 to
20 per 1000 between 1974 and 1984, a period when the country’s real
per capita fell from $5,184 to $4,844 (US$ at PPP, chain index; Penn
World Tables, 6.0). By the late seventies, these programs covered around
95% of all pregnant women and children (Idiart, 2004).
According to Foxley and Raczynsky, the drop in birth rates - especially
among the poor - accounts for 25-30% of the decline in infant mortality
during the 1974-1984 period (Foxley and Raczynsky, 1984:233).
McGuire argues that the rest of the drop was due largely to a reallocation
of health expenditure (McGuire, 2001). The military ruler, Augusto
Pinochet, cut spending on health care, but channeled much of what was
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CASE STUDIES
left to prenatal care; nutrition monitoring for children under six; intensive
care for malnourished children; and expansion of the PNAC’s coverage
to pregnant women, nursing mothers, and children under six (Hakim and
Solimano, 1978; Foxley and Raczynsky, 1984; Castaneda, 1992). In the
early eighties, in response to specific nutritional studies, the PNAC was
transformed into a targeted program strictly aimed at underfed children,
with a curative focus.
In 1990, the new democratic government began to promote strong social policies. Public health expenditure increased by 50% over the next
four years to tackle the deterioration of public infrastructure. A national
program for investment in infrastructure and equipment in public hospitals was implemented, for a total cost of US$500 million over six years
(Jimenez de la Jara, Bosset, 1995). Important investments were made
in primary care facilities to increase access to primary health care and
relieve the pressure on hospitals and emergency rooms. In addition,
throughout the 1990s, significant changes took place in regards to the
National Health Fund, FONASA, and the implementation of specific programs that impacted the health of mothers and children.
In 1994, the government transformed the FONASA from a public health
sector financial management agency into a Public Health Insurance. In
1996, FONASA launched the National Health Plan, a comprehensive
health package for the whole population, and set out to promote its
provisions among the public, amidst a strong campaign to attract
affiliates. In the same year FONASA launched the “Patients’ Rights Chart”
(Carta de Derechos de los Pacientes) and established Complaint Units all
over the country, alongside a national campaign to promote the right to
health. FONASA’s Health Plan and the “Patients’ Rights Chart” boosted
demand for quality health care, helped to increase the quality of health
services provision in the public sector, and ensured access to institutional
delivery and perinatal care.
Since the poor concentrate both high health risks and low ability to
contribute, FONASA set out, right after its transformation into the public
insurance, to diversify its risk pool by attracting different income and
population groups. In doing so, it pushed public providers to improve
quality of care. This strategy has allowed FONASA both to be financially
sustainable and to raise quality standards in health care provision all
over the system.
In 1995, the government launched the Family Health Plan,PSF, to be
delivered at the Municipal level. The Plan is a comprehensive primary
health care package aimed at meeting the family’s health needs, with
a focus on health promotion and preventive care. It includes family
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CASE STUDIES
planning, antenatal and post delivery care, newborn health check ups,
nutritional counseling, in-house visits, immunizations, and the delivery of
the PNAC’s benefits conditioned to health check ups. FONASA makes
per capita transfers to the Municipalities to ensure the delivery of the
Plan and the adequate referrals. The poorer and more remote the
municipality, the higher the per capita transfer. The Plan is delivered all
over the country. The midwife is the Program’s main human resource, and
the health team also has a general practitioner, a dentist, a nutritionist,
and a social worker (Castro and Camacho, 2004).
By 2002, the PNAC covered approximately 80% of pregnant women
and children under six years old. The program is universal and provides
supplements with different nutritional composition, delivered according
to nutritional status and conditional on health check-ups. Over the years,
the PNAC has allowed not only for the improvement of the nutritional
status of the mother and child population; it has also been effective in
promoting a primary health care-seeking behavior among its beneficiaries.
The program is currently complemented by another nutritional program,
this one delivered in the classroom to school age children (Programa de
Alimentación Escolar, PAE), in order to ensure the continuous provision
of nutritional care to this population (Idiart, 2004).
Table 29: PNAC coverage by age group, 2002
Total eligible population
Covered
population
Covered population
% of total eligible population
0-24 months
343,044
307,000
89.5%
25-72 months
679,508
518,000
76.2%
Total children
1,022,552
825,000
80.5%
93,617
80,903
86.4%
1,116,169
905,903
81.2%
Age
Pregnant women
Total PNAC
SOURCE: Riumallo J., Pizarro T., Rodriguez L., Benavides X. “Programa de suplementacion alimentaria y de fortificacion de alimentos con micronutrients en Chile”. Ministry of Health, Chile
For the purpose of this analysis, the benefits provided to the mother and
child population by the Public Health Insurance, FONASA, the Family
Health Plan, PSF, and the PNAC will be treated together, under the banner of MCHSHPP.
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CASE STUDIES
Table 30: Main Features of the MCHSHPP
Feature
Category
Type
- Public Health Insurance
- Free primary health care
- Conditioned in-kind transfer
Mode of financing
- Contribution- based insurance scheme
- Publicly funded
Source of funds
- General taxes
- Individual mandatory contribution
- Individual voluntary contribution
- Co-payments
Risk pooling arrangement
- Income-based (FONASA)
- Community-rated (PSF-PNAC)
Management and management
level
MoH at national/sub-national/local level
Local government (Municipalities)
Degree of selectivity
- Universal (FONASA, PSF)
- Targeted (PNAC)
Who is entitled to coverage
- Family (PSF)
- Individual/dependents (FONASA-PNAC)
Condition for access
- Citizenship (PSF-FONASA)
- Specific attribute: age/proof of childbirth/proof of pregnancy (PNAC)
Extent of risk pooling
Large pool (FONASA, PSF)
Small pool (PNAC)
Explicit portfolio?
Explicit
Degree of coverage
Comprehensive
Provision
Public-private
2 . CHARACTERIZATION OF THE GENERAL SETTING IN
WHICH THE SPHS IS IMPLEMENTED
Basic Information - Chile is an upper-middle income country situated
in the southern cone of South America. According to the latest Census
(2002), the country has a total population of 15,116,435 people, of
which 49.3% are men and 50.7% are women. The urban population is
86.6% and the rural population 13.4%. In 2001 the fertility rate was 2.0
children per woman, among the lowest in the region.
Economy - Poverty has been steadily decreasing in the country during the
last fifteen years, thanks to a mix of economic and social measures. The
75
CASE STUDIES
incidence of poverty dropped from 40% in 1987 to 18.8% in 2003, while
indigence was reduced from 13% in 1987 to 2% in 2001. In the same
year the unemployment rate was 8% and informal workers were around
10% of all workers (Ministerio de Salud de Chile- MINSAL 2004). According to the Central Bank, in 2002 the per capita income was US$ 4,127.
The country has enjoyed political stability after a wide social movement
defeated, through a national referendum, the military government that
had seized power in 1973 and ruled the country for 17 years.
Health and Education- Chile’s health indicators are among the best in
LAC. Along with Cuba and Costa Rica, it is considered to be one of the
few countries in the region that have succeeded in their efforts to satisfy
the basic needs of a large proportion of their population (Horwitz, 1987).
Life expectancy was 76.3 years in 2000 and prevalence of malnutrition
in children under five was 0.8% in 2001. In the year 2002, the youth
literacy rate (% ages 15-24) was 99% and adult literacy rate was 96%.
The maternal mortality ratio was 31 per 100,000 live births in 2001, with
99.5% of all deliveries attended by skilled health staff. In the same year,
total expenditure on health was 7% of GDP and public expenditure on
health was around 49% of the total. Of the 51% of private expenditure
on health, around 40% is used to pay premiums or make contributions to
public or private health insurance.
According to the World Bank (World Bank, 2000), Chile has achieved
considerable improvements in key social indicators - infant mortality, life
expectancy and educational coverage - through a combination of interventions in three important areas (education, health, and housing) and
its system of targeted social programs. The existence of a government
office specifically focused on social policy planning and evaluation of
social policies (the Ministry of Social Planning, MIDEPLAN) also seems to
play a role. Although there is a high income concentration in the country,
income adjustments through progressive social spending greatly reduce
the effect of economic disparities. The impact of social policies in reducing income inequalities has increased along with the budget allocation
to such programs. According to data from 2003, income transfers from
subsidies in education, housing, and health make up for around 40% of
the income increase of the households in the two lowest income quintiles
(Agostini and Brown, 2007).
The current Chilean health system is based on the concept of insurance
and has a mix of public and private insurers and providers. The public
insurance, called the National Health Insurance Fund (FONASA) is the
dominant insurer. FONASA serves 68.3% of the population, including
those who choose to enroll in the public insurance and those who due to
poverty or indigence cannot contribute and whose contributions are paid
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CASE STUDIES
by the government. On the provision side, the public sector - consisting
of the Municipal subsystem for primary care and the National Health
Services System for secondary, tertiary, and specialized care and complementary services - is the main provider and has an extensive service network all over the country. The whole system operates through a package
of health services. The private insurers - ISAPRES - may offer different
health plans, but they cannot provide fewer services than those provided
by the public insurance package. The insurer buys health services from
public or private providers to guarantee the coverage of the package to
its affiliates (MINSAL, 1999).
Although they operate under different systems, both insurance components - public and private, FONASA and ISAPRES - have the legal obligation to cover, in all plans, the following: i) preventive medicine exams;
ii) sick leave payments; and iii) comprehensive protection for pregnant
women and children under six years. The latest reform introduced in
the system in 2004 created the system of Universal Access with Explicit
Guarantees (Acceso Universal con Garantías Explícitas, AUGE), which
ensures access to a single national health plan in similar conditions of
quality, opportunity, financial protection, and health services delivery for
all people, regardless of whether the insurer and/or the provider are private or public. AUGE seeks to eliminate segmentation by standardizing
the content, costs and quality of the guaranteed portfolio of entitlements
within the system, and to reduce fragmentation regarding the insurance
plans.
Table 31: Chile’s general situation
Contextual factor
Deteriorates
Poverty
Demand for health
care
Health status
Improves
X
Hinders
Promotes
X
Education level
X
X
No. of rural dwelling/ remote settlements
X
X
Access to water/sanitation/electricity
X
Government’s institutional strength/fragility
X
X
Country’s governance
X
X
Unemployment
X
X
Labor informality
X
X
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CASE STUDIES
3 . ANALYSIS OF THE PERFORMANCE OF THE SPHS
a). Has it increased equity in the access to/utilization of
health services?
Although several inequity problems remain to be tackled in the Chilean
dual insurance health system, especially in the system’s financing mechanism, the three strategies under analysis have clearly increased equity in
the access to and utilization of health services. Successive evaluations of
the PNAC between the late 1970s and mid 1990s show that the program
has consistently had higher coverage for those in the two lower income
quintiles (MINSAL, 2000). Moreover, according to Idiart (2004), beneficiaries consider the program’s benefits as part of their citizen’s rights. The
current overall coverage of the program is around 80% of total Chilean
mothers and children under six.
According to Castro and Camacho (2004), the main explanation for the
impressive drop in maternal mortality in Chile has been the continuous
improvement in access to quality reproductive health care services for all.
For instance, between 1990 and 2000, the number of women using a
contraceptive method under the care of the public system had increased
by 34.5%. The Family Health Plan has allowed poor families and those
living in remote and/or poor municipalities to have access to the benefits
of primary health care. FONASA has been the key to increased equity in
the access to secondary, tertiary, and specialized health care and hospitalization for mothers and children.
b). Has it offset hindering social determinants?
Chile’s overall situation tends to contribute to good health. Most important social determinants, such as literacy rate, income, women’s status,
institutional strength, infrastructure, and governance all work to improve
health status. Those few that do not are ably tackled by the SPHS under
review. The Family Health Plan has contributed to overcoming the negative social determinant of living in a poor and/or isolated community,
while FONASA has helped to offset poverty and difficult employment
conditions (unemployment, informality).
The programs and benefits reviewed in the previous sections have all
contributed to fostering women’s status and rights in Chilean society. FONASA took the lead in promoting the right to health with its “Patients’
Rights Chart” (Carta de Derechos de los Pacientes), which boosted the
demand for quality health care among all Chileans, regardless of their
social or economic status. The PNAC has been effective in promoting
the rights of pregnant women, mothers and children to health care and
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CASE STUDIES
adequate nutrition. PNAC has also been successful in promoting primary
health care-seeking behavior among its beneficiaries, thus fostering the
demand for health care especially among mothers and pregnant women
(Idiart, 2004).
Table 32: Performance of the MCHSHPP: social determinants
Category
Performance
yes
Offsets poverty by eliminating or reducing economic barrier
X
Fosters women’s social status
X
Fosters health rights through Right Charts, explicit guarantees, etc.
X
Offsets unemployment/informal labor by eliminating or reducing economic barrier
X
Offsets women’s lack of education, fostering demand for health care
X
no
c). Has it increased access to and coverage of technically
appropriate interventions by eliminating at least one
source of exclusion in health?
The observed increases in coverage of and utilization of services by
the poor suggests that the Maternal and Child Health Protection Plan
has been successful in removing the economic barrier to access to primary health care services, complementary nutrition and hospitalization,
and specialized services. Moreover, the fact that the self-employed may
choose between the ISAPRE (Instituciones de Salud Provicional) and FONASA, while indigents are covered by FONASA, overcomes unemployment and informality as barriers to access health care. By 2001, the PSF
had reached over 90% coverage of antenatal care and 100% immunization coverage. Skilled attendance at birth rose from 45% in 1952 to
99.7% in 2000.
Castro and Camacho (2004) report that the important drop (76.5%)
during the period 1990-1998 in the rate of maternal mortalities linked
to postpartum sepsis was due to the Intra Hospital Infections Control Program, developed as a component of the Hospital Accreditation System.
However, problems related to waiting times, quality of care, hours of
operation, and patient satisfaction still persist.
Public spending allocated to the schemes has steadily increased over
time and shows a progressive pattern. As mentioned above, in the early
1990’s a national program of investment in infrastructure and equipment
in public hospitals was implemented to prepare the ground for the upcoming reforms, and important investments were made in primary care
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CASE STUDIES
facilities. Households, however, remain an important source of financing
for the sector, contributing 51% of total expenditure on health.
Eliminating geographic barriers is important in a country with geography
as whimsical as Chile’s. FONASA’s practice of taking poverty and geographical isolation into account when administering the Family Health
Plan has contributed to overcoming geographic and economic barriers
to access to primary health care. The need to integrate PNAC, FONASA,
and the Family Health Plan also prompted the creation of a unified information system that allows for gathering, recording, and managing data
from all over the country on a regular basis.
The implementation of the dual insurance model in the ‘80s did have
the effect of introducing segmentation into the Chilean health system.
The latest reforms, introduced with the creation of AUGE in 2004, focus
specifically on eliminating segmentation. Their outcomes will surely be
analyzed in the years to come.
Table 33. Performance of MCHSHPP: coverage and access
Category
SPHS
yes
Increases coverage (rise in number of people covered as a % of eligible population)
X
Establishes a single guaranteed portfolio of entitlements with the same quality, content,
and delivery conditions for all socioeconomic groups so as to avoid segmentation
X
Increases coordination/integration within the system so as to avoid fragmentation
X
Improves resource allocation and organization of health interventions by increasing number and capabilities of human resources in previously underserved areas
X
Improves resource allocation and organization of health interventions by increasing the
amount of public spending allocated to the scheme
X
Public spending allocated to the scheme is progressive
X
Improves geographical distribution of the service delivery network and health infrastructure
by increasing number/amount of health facilities, equipment, medical devices, and drugs
in previously underserved areas
X
Increases information system’s coverage
X
Increases access (rise in number of people with access to health goods or services provided by the scheme)
X
Eliminates/reduces geographic barrier
X
Eliminates/reduces economic barrier
X
Eliminates/reduces gender barrier
Eliminates/reduces employment status barrier
80
no
X
X
Improves access to drinkable water, sewerage, roads, and/or transportation
X
Improves refuse collection
X
CASE STUDIES
d). Have health outcomes improved?
Infant and maternal health and nutrition outcomes have dramatically
improved in Chile in the past decades. According to statistics from the
Ministry of Health, Maternal Mortality dropped from 40 per 100,000 live
births in 1990 to 17 per 100,000 live births in 2002. The main causes of
this reduction are the increase in skilled attendance during childbirth and
family planning interventions to prevent unwanted pregnancies (MINSAL,
2004). According to the same source, the data show a sustained downward trend in infant mortality over the past sixty years. In 1950, IMR was
136 per 1,000 live births; in 1970 the rate dropped to 79 per 1,000 live
births; in 1980 it fell to 31.8; in 1990 it dropped to 16.8; and in 2002,
it was only 7.8 per 1,000 live births. The main causes of this decline are
the increase in utilization of skilled attendance during childbirth and periodic pediatric primary care, as well as PNAC and higher family income
(MINSAL 2004).
Table 34: MCHSHPP’s performance
Goal
Performance
Increase equity in the access to and/or utilization of health services
It has increased equity in the access to and
utilization of health services provided by the
program
Offset social determinants that hinder demand
for health care and/or hamper health status
The policy has helped to offset poverty and
living in isolated and poor communities. It
has fostered the demand for health care by
promoting health rights.
Increase access to and coverage of technically
appropriate health interventions by reducing or
eliminating at least one cause of exclusion in
health
It has increased access by reducing the
economic and geographic barriers. It has
increased coverage (human resources, health
facilities) in previously underserved areas
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CASE STUDIES
5.4
Free Maternity and Child Care Law (Ley de
Maternidad Gratuita y Atención a la
Infancia, LMGYAI) ECUADOR
1 . CHARACTERIZATION OF THE SPHS
Ecuador experienced high maternal and child mortality rates throughout
the 1990’s: the INEC (Instituto Nacional de Estadísticas y Censos de
Ecuador) Vital Statistics Yearbook reported that in 1990 the maternal
mortality ratio was 117 deaths per 100,000 live births, and the infant
mortality rate 30 deaths per 1,000 newborns. In 1994, in response to the
challenge of high mortality rates, the government passed the first version
of the Law for the Provision of Free Maternity and Child Care (LMGYAI).
The law has since gone through extensive reforms, most importantly in
1998 and in 2000, when it was amended to improve resource allocation
and managerial mechanisms. The Law states that every woman has the
right to free quality health care, both during pregnancy and postpartum,
and that every child under five years old has the right to care for the most
common childhood diseases. One of the main contributions of the LMGYAI is that it establishes a legal and financial framework for the continuity
of public health policies aimed at women and children, despite frequent
changes in government caused by the country’s political instability.
The main features of the LMGYAI are:
1. The law redefined the role of the State in the provision of social protection in health to women and children by guaranteeing access to an
explicit package of free health services for mothers and children, attempting to eliminate the economic barriers that prevent vulnerable groups
from accessing health care.
2. The law works through mechanisms that encourage an improvement
of quality and accountability in the provision of health services, such as
clinical guidelines, calculation of costs for reimbursement of services,
and management agreements with municipalities for co-management of
health care services (Hermida J. et al., 2005).
3. The law relies on social participation, through the organization of
users’ committees, to ensure the quality and responsiveness of health
services delivery.
Two elements were the driving force in the creation of the LMGYAI: the
role played by national and international women’s movements in pressuring the state to address women’s needs and the momentum created by
the health sector reform process in Ecuador. It is noteworthy to mention
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CASE STUDIES
the role of the Women’s National Counsel (Consejo Nacional de las
Mujeres, CONAMU) in the creation of the LMGYAI. CONAMU was a
vocal advocate for reproductive health and held the state responsible for
protecting women and children’s right to health and for creating a stable
source of funding to face the challenge of high maternal and infant mortality rates (Quality Assurance Project, 2004).
The passing of the LMGYAI resulted in the creation of the Free Maternity
Program, a public program under the auspices of the Ministry of Public Health (MSP). The goal of the Free Maternity Program is to reduce
maternal, female, and infant mortality rates by increasing coverage of
health care, undertaking health promotion activities, providing a better
response to obstetric and pediatric emergencies, and developing a decentralized and participatory health care model.
Originally, only nine health interventions were covered by the LMGYAI.
New interventions were added by the end of 2002, and as of 2003 the
law included 42 interventions (see table 35). The increase was based
on the Law’s regulations, public need, and the consensus among the
institutions that support and monitor the Law’s implementation (Quality Assurance Project, 2004). The law states that the services, provided
through the facilities of the Ministry of Health, should be available to
the beneficiary population throughout the country and at all provision
levels. Non-profit institutions and traditional medicine agents have access to the funds after completing an accreditation process and with the
understanding that services must be provided free of charge (Ministry of
Health, 2005).
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Table 35: Interventions provided by LMGYAI, 2003
Services Provided to Women
Services Provided to Children Under 5
Antenatal Control
Immediate care to newborns
First Control
Subsequent Controls
Dental Care
HIV/AIDS Diagnosis
Diagnosis of congenital anomalies
Early identification and referral of pregnant women
by a community agent
Early referral of high-risk pregnancies
Delivery
Normal Delivery
Cesarean Section
Early referral by a community agent, resulting in
normal delivery or cesarean section
Obstetric Emergencies
Pregnancy-induced hypertension
Hemorrhage during the first half of pregnancy
Hemorrhage during the second half of pregnancy
Hemorrhage during delivery and post partum
Sepsis
Immediate postpartum care
Care of healthy newborns
Diagnosis and treatment of congenital hypothyroidism
Care of low-weight and pre-term newborns
Intensive and intermediate care of perinatal
asphyxia
Intensive and intermediate care of perinatal jaundice and septicemia
Health care to children under five years old
according to the Integrated Management of
Childhood Illnesses (IMCI) strategy
Under 1 year old well-child check-up
Under 5 years old well-child check-up
Dental care
Detection and treatment of child abuse
Early identification and referral of children under 5
by a community agent using IMCI
Intra-hospital complications
Blood and blood products transfusion
Postpartum control
Postpartum referral and referral of newborns under
7 days
Detection and referral of women with hemorrhage
and postpartum complications
Family Planning and Reproductive Health
Counseling and prevention
Detection and treatment of intrafamily violence
against women, including medical forensic analysis
Bilateral tubal sterilization
Vasectomy
Daily Oral Contraceptive-DOC women 34-64 years
old
Early detection of breast cancer in women 34-64
years old
Sexually Transmitted Diseases-STD
Diagnosis and
Diagnosis and
Diagnosis and
Diagnosis and
Diagnosis and
treatment of Syphilis
treatment of Gonorrhea
treatment of Genital Herpes
treatment of Papilloma Virus (HPV)
treatment of leucorrhea
Blood and blood products transfusion
SOURCE: Quality Assurance Project. “Ley de Maternidad Gratuita y atención a la Infancia del Ecuador
(LMGYAI)” February, 2004.
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CASE STUDIES
Funding for the implementation of the LMGYAI comes from a variety of
sources, including (Quality Assurance Project, 2004):
1. Government resources – 3% of the revenues of Tax on Special
Consumption (Impuesto a los Consumos Especiales, ICE).
2. International multilateral and bilateral cooperation agencies:
USAID, AECI, UNFPA, UNICEF, PAHO, and the World Bank.
3. Solidarity Fund for Human Development: USD$ 15 million per
year.
4. National Fund for Infant Nutrition (FONNIN): USD$ 3 million
per year.
5. Local municipalities (fiscally responsible for transportation, treatment resulting from obstetric and pediatric emergencies, and
health promotion activities).
The budgetary allocation for the LMGYAI has not been sufficiently constant to ensure the continuity and effectiveness of the program. According to the ILO, between 2001 and 2002 the budget for the LMGYAI
decreased 54%, from US$ 10.4 million to US$ 5.6 million, or from
3.62% to 2.08% of the total budget allocated to social programs (ILO,
2003). Reports from the government indicate that the budget allocated
to LMGYAI increased to US$ 21.9 million in 2004 (Children Rights Committee, 2005). Unstable budget allocation and the difficulty of reaching
poor and indigenous communities have been the main obstacles faced in
implementing the LMGYAI (Government of Ecuador, National Secretariat
for the Attainment of the MDG’s 2006).
Although the implementation of the LMGYAI is financed by the government, the campaign to reduce maternal and infant mortality has benefited from strong technical and financial support from international
multilateral and bilateral cooperation agencies over the years. USAID,
UNFPA, UNICEF and PAHO/WHO made investments in maternal and
child health, and the public health projects financed by the World Bank
made the reduction of maternal and infant mortality one of their main
priorities (Hermida et al., 2005).
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Table 36: LMGYAI’s main features
Feature
Category
Type
Free maternal and child health care
Mode of financing
Publicly funded
Source of funds
General taxes
Other revenues (Extra budgetary sources: AECI, USAID, UNFPA, UNICEF, PAHO, and the World Bank.)
Risk pooling arrangement
Income-based
Management and management
level
MoH at national/sub-national/local level
Degree of selectivity
Targeted: women of reproductive age and children under five years old
Who is entitled to coverage
Individual
Condition for access
Specific attribute: age/proof of childbirth/proof of pregnancy
Extent of risk pooling
Small pool
Explicit portfolio?
Explicit
Degree of coverage
Complementary
Provision
Public/private non-profit
2 . CHARACTERIZATION OF THE GENERAL SETTING IN
WHICH THE SPHS IS IMPLEMENTED
Basic Information and Demographics - Ecuador is a lower-middle income
country located in the Andean region of Western South America, bordering the Pacific Ocean, Colombia, and Peru and straddling the Equator.
The country is characterized by great geographical, economic and ethnic
diversity. According to the Ministry of Health, the estimated population in
2005 was 13,215,089 inhabitants (MSP, 2005). According to the National Census of 2001, 61% of the total population is urban and 39%
rural. The total literacy rate for adults (% of people ages 15 and above)
is 91.6%.
It is estimated that indigenous people and those of African descent represent about 30% of the total country’s population, although figures vary
widely. There are 13 officially designated non-Hispanic ethnic groups
or nationalities in Ecuador, with the Runa and Quechua constituting
around 90% the indigenous population. Poverty and social exclusion is
closely linked to indigenous origin in Ecuador (ECLAC, 2005; PAHO/
WHO-SIDA, 2003). Nevertheless, after a long and arduous process, indigenous groups have built complex social organizations rooted in the
community level. Indigenous organizations have become stronger and
are increasingly recognized as political and social actors in the country’s
public sphere.
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Economy - Ecuador has important oil resources, which account for
around 40% of the country’s earning from exports and one-third of central government budget revenues in recent years (World Bank, 2006). In
the late 1990’s, Ecuador experienced a severe economic crisis, which
resulted in a steep economic recession and a contraction in real income.
Sharp declines in world petroleum prices drove Ecuador’s economy into
free fall in 1999 and poverty worsened significantly. Between 1995 and
2000, the number of those living in poverty increased from 3.9 to 9.1
million, and in extreme poverty from 2.1 to 4.5 million. In 2000, on
the brink of hyperinflation and in the middle of a serious political crisis, the Congress approved several structural reforms that provided the
framework for the adoption of the US dollar as legal tender. Although
dollarization stabilized the economy and the annual growth increased
from 2.8% in 2000 to 6.9% in 2004, poverty continues rampant in the
country. By 2004, 45% of the population was living under the poverty
line (World Bank, 2006). Other sources put this figure as high as 70%
(Ministry of Health, 2005). Ecuador has the second highest Human Poverty Index in South America and, according to the Unmet Basic Needs
Index, 60% of Ecuadorians live in poverty (ECLAC, 2005). By 2005, the
official unemployment rate was 9.7% with an underemployment of 47%.
According to ILO, in 2003 urban informal sector in Ecuador accounted
for around 57% of the total urban working population (ILO, 2005).
Health and Education- Life expectancy at birth was 70 years of age for
both sexes, and the percent of population aged 60 years or more has increased from 6.3 in 1993 to 7.5 in 2003. From 1993 to 2003 there was
a decline in the total fertility rate, from 3.5 to 2.7 children per woman
(WHO 2005). This may be due in part to the increase in women’s educational levels, their entry in the labor market, and the migration from
rural to urban areas.
Ecuador’s demographic, cultural, and social heterogeneity continues to
be a source of economic inequality and stark differences in living standards and health conditions. In the Amazon region, for example, where
there is a markedly higher concentration of indigenous and poor populations, premature deaths are frequent and life expectancy from 19952000 was unchanged at 59.6 years. An estimated 21% of the population in the Amazon will not survive more than 40 years, whereas in the
province of Pichincha life expectancy was almost 15 years longer (74.5
years), and only 6.8 percent of the population was expected to die before
age 40. Similar inequalities can be seen when life expectancies are stratified according to household consumption per capita: the populations of
low consumption provinces have a lower life expectancy than those of
provinces with greater resources (World Bank, 2005). Around 67% of
the total population has an adequate water supply and 57% has access
to sanitation, with large disparities between urban and rural dwellings
(Government of Ecuador: National Report on MDGs, 2005).
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The reported estimated maternal mortality ratio for the period 1999-2004
was 80 per 100,000 live births, while the adjusted maternal mortality
ratio in 2000 was 130 per 100,000 live births (PAHO 2004, UNICEF
2006). According to the Demographic and Maternal and Child Health
Survey (Encuesta Demográfica y de Salud Materna e Infantil, ENDEMAIN
2004), in the period 1999-2004 the estimated infant mortality rate was
29 per 1,000 live births and the under-five mortality rate was 34.0 per
1,000 live births. These figures hide significant disparities seen when results are stratified by the mother’s ethnic background. Thus, the infant
mortality rate in children of indigenous mothers - 40 per 1,000 live births
- is 48% higher than among children of mestizo (mixed Amerindians and
white) mothers (27 per 1,000 live births), while under-five mortality rate is
50% higher in children of indigenous mothers - 48 per 1,000 live births
- than among children of mestizo mothers - 32 per 1,000 live births.
23% of all children under five years old suffer from chronic malnourishment. This figure increases to 47% in children of indigenous mothers.
It is noteworthy that the reliability of child and maternal mortality data
based on statistical records has been disputed, and estimations based on
demographic surveys indicate rates that are significantly higher (World
Bank, 2005).
In 2002, total expenditure on health was 4.8% of GDP and public health
expenditure was 36% of total health expenditure. Per capita total expenditure on health was US$ 197.00 (WHO, 2005).
Ecuador has suffered enormous political instability over the last two decades. This in turn has led to economic and fiscal instability, with significant volatility in the budgets allocated to health and education. Social
spending is insufficient, regressive, and fragmented. An evaluation performed by the World Bank (World Bank, 2002) found that:
a) Compared to international standards, Ecuador underperforms in terms
of education and health outcomes, even after controlling for differences
in the level of development.
b) Social expenditure, especially on education and health, has declined
over time and tends to be pro-cyclical, so that the least resources are
available when they are needed the most.
c) Health spending declined from 1.3% of GDP in 1981 to 0.6% of
GDP in 2000. This reduction, along with that in spending on education,
seemed to lead to a transfer of emphasis from education and health
sectors to the social assistance, especially after introduction of the Bono
Solidario.
d) The budget allocated to the social sector is highly volatile, hampering
the continuity and effectiveness of social programs.
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The population of Ecuador faces a dangerous combination of high levels
of poverty and low access to institutional health services, and challenges
exist in the organization, management, and financing of the health sector. In 2000, 25% to 30% of the population did not have access to
institutional health services, and three-quarters were not covered by any
health insurance (PAHO/WHO, 2001(a)). In 1998, a series of reforms
established the right to health and made the Ministry of Health responsible for drafting state policies in the sector. The reforms also envisioned
a restructuring of the health sector through the creation of a National
Health System based on universal coverage, decentralization of management, and participation of local governments and social organizations
(PAHO/WHO, 2001(a)).
Ecuador’s health system is deeply segmented and consists of public, for
profit, and non-profit private health institutions, each of them focused
on different population segments according to income (although the
extremely poor are not reached by any of them) (PAHO, 2003). The
Ministry of Public Health (MSP) and the Ecuadorian Social Security Institution (IESS) are the main public sector institutions. Ecuador’s health
care system is also highly fragmented (PAHO, 2003). Within the Ministry
there are small networks, called Health Areas and defined by geographical and population boundaries, that follow a decentralized management
model, especially in certain administrative, programming and budgetary
activities. The IESS also operates under a decentralized administration,
working within nine regions, each of which has a network of services that
operate following central planning and financial directives. Each institution has its own management, organizational, and financial structure.
These institutions do not articulate or coordinate, making it very difficult
to draft a national plan to promote coverage and quality in the delivery of health services (PAHO/WHO, 2001(a)). This has led to an inefficient, inequitable, poor quality, and largely inaccessible system, with over
70% of the population uninsured (PAHO, 2003). The Ministry of Health
and other public institutions face severe constraints on their provision
of healthcare services to nearly half of the population. The share of the
population currently covered by contributory health insurance is amongst
the lowest in LAC and the poorest socio-economic groups have very little
access to health care (World Bank, 2006). According to a study conducted by PAHO/WHO in 2000, the incidence of exclusion in health in
the country is 51%. The main causes of exclusion are the deficit of public
health infrastructure and shortage of physicians (PAHO, 2003).
Status of Women - Women in Ecuador are faced with intra-family violence, discrimination, and difficulties asserting their reproductive and
sexual rights. They are discriminated against for two main reasons: because of their gender and because of their indigenous origin. Although
women enjoy the same legal status as men, the Office of Gender report-
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ed in 2005 that women often did not accede to equal rights in practice.
Women receive approximately 65% of the pay received by men for equal
work and there are fewer women than men employed in professional
work and skilled trades. Although the law prohibits violence against
women, including within marriage, abuses are widespread (US Bureau of
Democracy, Human Rights and Labor, 2006). Despite legal protections
of women’s rights in politics, the home, and employment, discrimination against women is pervasive, particularly with respect to educational
and economic opportunities for those in the lower economic strata. For
example, despite increases in overall education, 12% of women are illiterate compared to 8% of men (PAHO/WHO, 2001(a)).
Table 37: Ecuador’s general situation
Contextual factor
Deteriorates
Poverty Rate
Demand for health
care
Health status
Improves
X
Education level
X
Access to water/sanitation/electricity
X
Government’s institutional strength/fragility
X
Country’s governance
X
Unemployment Rate
X
X
X
X
X
X
X
3 . ANALYSIS OF THE STRENGTHS AND WEAKNESSES
OF THE SPHS
a). Has it increased equity in the access to/utilization of
health services?
Recent analyses report mixed outcomes in terms of access and equity.
Vos et al. (2004) found that inequalities in access to health facilities have
increased, partly because of the introduction of user fees and partly because health inputs, especially supply of drugs, have fallen well behind
requirements (Vos et al., 2004). By the end of 2003, only about 30%
of pregnant women were covered by the program, which reaches out
to only a small portion of the most vulnerable groups. Coverage is only
19% among indigenous and rural women and only 20% of the poorest
third of the population. According to official government reports, impor-
90
Promotes
X
X
No. of rural dwellings/remote settlements
Labor informality
Hinders
CASE STUDIES
tant gaps remain in the access to health care for mothers and children
of indigenous origin living in rural communities, and the poorest women
remain excluded from the benefits of the law (Government of Ecuador:
National Report on MDGs, 2005). To tackle this situation, the government is currently designing a Universal Health Insurance (Government of
Ecuador, National Secretariat for the Attainment of the MDG’s 2006).
b). Has it offset hindering social determinants?
The LMGYAI fosters knowledge of health rights by guaranteeing access
to an explicit package of free health services for mothers and children
and by relying on social participation to safeguard the quality and responsiveness of health services delivery. Moreover, it promotes women’s
social status by implementing mechanisms through which women may
exert their reproductive and sexual health rights. Despite some difficulties, during the first years of the law’s implementation, in making the
guarantee of free-of-charge provision of the health services included in
the package effective, recent reports inform that the LMGYAI has effectively lowered the economic barrier to health for the target population
(Hermida J., et al., 2005). According to ENDEMAIN 2004, from 1994 to
2004 there has been an increase in the percentage of mothers receiving
prenatal health care (from 75% to 84%) and in institutional deliveries
(from 64% to 75%) but only a 3% increase in postpartum health care,
from 33% to 36%. However, as of 2004, only 50% of total live births in
the rural areas had prenatal care and institutional delivery and only one
third of indigenous and illiterate mothers benefited from prenatal care
and institutional delivery (ENDEMAIN 2004).
Table 38: LMGYAI’s performance: social determinants
Category
Performance
yes
Offsets poverty by eliminating or reducing economic barrier
X
Fosters women’s social status
X
Fosters health rights through Right Charts, explicit guarantees, etc.
X
Offsets unemployment/informal labor by eliminating or reducing economic barrier
X
Offsets women’s lack of education, fostering demand for health care
no
X
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c). Has it increased access to and coverage of technically
appropriate interventions by eliminating at least one
source of exclusion in health?
The number of women and children who received health services covered by the LMGYAI increased from 1,600,000 in 1999 to 3,867,000
in 2004, which means that coverage more than doubled in five years of
the program’s implementation. As the table below shows, access to the
services provided by the law has increased. The results could also be due
to the fact that the number of services provided by the LMGYAI increased
as the law underwent revisions (Quality Assurance Project 2004).
Despite the efforts of the Government of Ecuador to improve maternal
and child health, approximately 20% of births are still unattended (INEC,
2005). This national average hides much larger percentages in some
areas: while less than 12% of births in urban areas are unattended, 49%
of all rural births take place without assistance, a figure which rises to
more than 70% in the Amazon region (INEC, 2005).
Graph N. 3
Persons Receiving Services Under
LMGYAI, 1999-2004
4000000
3000000
2000000
1000000
0
1999
2000 2001 2002 2003 2004
SOURCE: Quality Assurance Project. (February
2004).Research Report # 62: The Law for the Provision of Free Maternity and Child Care (LMGYAI)
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Table 39: LMGYAI: Coverage and access
Category
SPHS
yes
Increases coverage (rise in number of people covered as a % of eligible population)
X
Establishes a single guaranteed portfolio of entitlements with the same quality, content, and
delivery conditions for all socioeconomic groups so as to avoid segmentation
X
no
Increases coordination/integration within the system so as to avoid fragmentation
X
Improves resource allocation and organization of health interventions by increasing number
and capabilities of human resources in previously underserved areas
X
Improves resource allocation and organization of health interventions by increasing the
amount of public spending allocated to the scheme
X
Public spending allocated to the scheme is progressive
X
Improves geographical distribution of the service delivery network and health infrastructure
by increasing number/amount of health facilities, equipment, medical devices, and drugs in
previously underserved areas
X
Increases information system’s coverage
X
Increases access (rise in number of people who access to health goods or services provided
by the scheme)
X
Eliminates/reduces geographic barrier
X
Eliminates/reduces economic barrier
X
Eliminates/reduces gender barrier
X
Eliminates/reduces employment status barrier
X
Improves access to drinkable water, sewerage, roads, and/or transportation
X
Improves refuse collection
X
d). Have health outcomes improved?
Ecuador still has high rates of neonatal, infant, and maternal mortality from preventable causes. Available data does suggest a significant
decline in maternal mortality coinciding with the program’s commencement. According to INEC statistics, the maternal mortality ratio dropped
from 117 per 100,000 live births in 1990 to 53 in 1998, although
there are some concerns about high under reporting (Quality Assurance Project 2004). And despite the sharp decline in the MMR (Maternal
Mortality Ratio) in the first half of the 90’s, the rate rose again to 77.8
in 2003 (INEC 2003). The CDC puts the rates even higher, at 107 in
2004, suggesting the possibility that the perceived rise in MMR might
be the result of better reporting and not actually higher rates (USAID,
2003-7). Considering that the LMGYAI was first implemented in 1994
with pregnant women as its main beneficiary and was heavily revised in
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CASE STUDIES
1998 to incorporate several additional provisions, we would expect to
see a greater impact on maternal mortality.
According to UNFPA, the LMGYAI has not been effective in reducing maternal mortality and morbidity due to serious implementation constraints
caused by a) insufficient resources allocated to the program and b) lack
of organization in decentralizing those resources (UNFPA, 2005).
Graph N. 4
Ma t e r n a l M o r t a l i t y U n d e r L M G Y A I , 1 9 9 0 - 2 0 0 4
225
175
Q A P R a t i os
C D C R a t i os
125
75
25
1990
1995
2000
2003
2004
Source: Quality Assurance Project. (February 2004).
Research Report # 62: The Law for the Provision of Free
Maternity and Child Care (LMGYAI); USAID Country Health
Statistical Report: Ecuador, 2003-2007
The same trend is observed when examining Infant Mortality Rates (IMR).
Infant mortality dropped from 140 in 1950-55 to 33 per 1,000 live births
in 1995-2000. This downward trend coincides with a long-term decline
in fertility, from 7 children per woman in 1950 to 2.8 in 2000-05. The
graph below shows that IMR further declined from 30.3 per 1,000 live
births in 1990 to 18.5 in 2000. However, in 2003, the IMR was 22.3. It is
not clear whether the initial decline in infant mortality and the subsequent
increase in the rate registered in 2003 are related to the application of
the Law due to its relatively low coverage among children.
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Graph N. 5
Infant Mortality Under LMGYAI, 1990-2006
35
30
QAP Rates
BUCEN-IDB Rates
25
20
15
1990
1995
2000
2003
2004
2006
2005
SOURCES: Quality Assurance Project. (February 2004).
Research Report # 62: The Law for the Provision of Free
Maternity and Child Care (LMGYAI); USAID Country
health statistical reports: Ecuador, 2003-2007
Table 40: LMGYAI’s performance
Goal
Performance
Increase equity in the access to and/or utilization of
health services
Inequalities in access to health facilities persist and in
some cases they have increased
Offset social determinants that hinder demand for
health care and/or hamper health status
It fosters health rights and women’s status
Increase access to and coverage of appropriate
health interventions by reducing or eliminating at
least one cause of exclusion in health
It has increased coverage of health services included
in the package. It has increased access by reducing
the economic barrier
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5.5
Mother and Child Voucher (Bono MaternoInfantil, BMI) HONDURAS
1 . CHARACTERIZATION OF THE SPHS
The Mother and Child Voucher (BMI) is part of the Family Allowance
Program (Programa de Asignación Familiar, PRAF), a larger initiative,
launched in 1990 by the Government of Honduras and supported by the
Inter-American Development Bank, to provide a safety net for the poorest that would protect against food insecurity and malnutrition during
periods of economic adjustment (IDB 2006). The PRAF is administered
by the Office of the President and consists of cash transfers under three
components: School Voucher (Bono Escolar, BE), Elderly Voucher (Bono
para la tercera edad), and the BMI. According to a report prepared for
the World Bank, as of 2002 the three cash transfer programs altogether
reached only 4.7% of the total population of the country (Ayala Consulting Co., 2003).
The BMI consists of cash transfers, given to mothers through public health
care facilities, in the amount of Lps.50 (approximately US$3.00) per
month per child. The delivery of the financial incentive is conditioned on
the utilization of health services in the participating public health facilities.
The program was implemented as a response to high rates of malnutrition and poverty and with the following goals:
i)
ii)
iii)
iv)
to complement the income of the poor;
to reduce food insecurity;
to alleviate malnutrition during periods of economic adjustment; and
to promote utilization of preventive and curative health care
services for mother and child populations.
The program targets families with pregnant and/or breast feeding women, children under 5 years of age, and/or disabled children under 12
years of age. To be eligible, the families must have an income of less
than US$ 36.00 per year; must have three or more unmet basic needs
such as food, health care, or sanitation; and must participate in periodic
antenatal check-ups, immunizations, and wellness check-ups for the children, as well as training programs in health and nutrition (IDB, 2002).
The transfer is in the form of a voucher to the mother, who decides how
it will be used. In its first stage, in the context of PRAF-I (1990-1998) the
BMI aimed at 203,600 beneficiaries. An evaluation of PRAF-I performed
by the IDB showed that the BMI had reached 84% of its target population. It also noted some problems in the implementation of the program
(IDB, 2002). These were:
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CASE STUDIES
1. A preoccupation with the process of voucher distribution rather
than results
2. Poor targeting, since 40% of BMI beneficiaries were in the two
highest quintiles
3. Little evidence that demand incentives per se were improving
health and/or nutritional status of the targeted population
Seeking to improve its outcomes, the program’s second stage, PRAF-II
(from late 1998 to present) seeks to make the transition from a model of
social compensation to one of capital accumulation by the poorest families. To this end, the following changes were proposed (IDB, 2002):
a) Improve targeting towards the poorest families
b) Improve monitoring and evaluation capabilities
c)
Improve information and management systems
d) Offer both supply and demand incentives to induce behavior modification both in the households as well as among
services providers
e) Replace the single BMI voucher with two different subsidies:
i) a US$ 48 per capita per year transfer (maximum two per
family) to promote better nutrition for children and pregnant
women and foster their demand for health care. The goal is
to provide 69,000 subsidies per year. ii) a supply-side subsidy
to encourage NGOs to provide nutrition and hygiene training
to approximately 27,000 people, and a transfer of US$ 5,000
each to around 150 rural health centers to provide adequate
health services to PRAF beneficiaries
The program’s targeting mechanism has changed over time. Until 1998,
beneficiaries were selected first based on the prevalence of stunting and
poverty, and secondly according to their score on the Unmet Basic Needs
index. PRAF-II attempted to create a simpler system, choosing municipalities based on malnutrition and families based on household income
(Hernández, F., 2006). While PRAF-I continues in operation, PRAF-II is
currently being implemented in 70 municipalities located in the seven
poorest departments of the country (Government of Honduras-Office of
the President, 2005), replacing PRAF-I in those municipalities.
The health portion of the program consists of a biannual transfer, totaling
Lps644 per beneficiary (about 33 dollars per year). Each family is limited
to two beneficiaries. Health transfers may be complemented by education supplements for older children, which are dependent on school attendance and which are slightly larger (Lps812, or about 42 dollars, per
year for up to three beneficiaries) (International Food Policy Research
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Institute, 2004). Handa and Davis estimated that the average beneficiary family receives 17 dollars a month from all PRAF benefits, which
represent 8% of monthly income at the poverty line and 10% of monthly
household spending (Handa and Davis, 2006). Benefits are set to rise
dramatically in the coming years, ranging from Lps3,300 to as much
as Lps4,300 (135 to 225 dollars) per beneficiary per year (Hernández,
F., 2006). This rise will make the cash transfer a much larger portion of
household income, more closely approximating the benefits of Mexico’s
OPORTUNIDADES program.
Since 1998 the BMI also includes a supply-side subsidy, called Incentive to Quality in Health (ICS) and aimed at health providers (León A.,
Martínez R., Espíndola E., and Schejtman A. 2004). The ICS consists of a
basic package of drugs and medical equipment as well as funds to train
and provide performance incentives to health workers, cover expenditures for obstetric emergencies, and provide nutrition and hygiene training to mothers. Funds per center vary from Lps. 90,000 to 220,000 per
year, depending on the size of the population to be served, the amount of
health workers, and the specific health center’s requirements.
Although the BMI has a national scope, it has not yet reached national
coverage. As of 2004 it was implemented in 211 of 298 municipalities,
including La Paz, Valle, Ocotepeque, Santa Barbara, Copan, Olancho,
Comayagua, El Paraíso, and Francisco Morazán. According to government documents, between 1990 and 2005 the BMI benefited nearly 1.5
million people (Hernández, F., 2006). Between 1998 and 2004, around
4% of the beneficiaries - 22,618 people - were breast feeding or pregnant women (Government of Honduras, Office of the President, 2005).
Funding for the BMI comes from the national budget, as well as from
the IADB, UNESCO, the European Union, UNICEF, PAHO, and bilateral
agencies.
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Table 41; Main features of the BMI
Feature
Category
Type
Conditioned cash transfer
Mode of financing
Publicly funded social assistance
Source of funds
General taxes
Other revenues (Extra budgetary sources: IDB, AECI, USAID,
UNESCO, UNICEF, PAHO, European Union)
Risk pooling arrangement
Income-based
Management and management level
MoH at national/sub-national/local level
Degree of selectivity
Targeted: pregnant or breast-feeding women, children under five
years old and disabled children under 12 years of age
Who is entitled to coverage
Family
Condition for access
Means tested specific attribute: proof of income/age/proof of childbirth/proof of pregnancy
Extend of risk pooling
Small pool
Explicit portfolio?
Explicit
Degree of coverage
Complementary
Provision
Public/private non-profit (NGOs)
2 . CHARACTERIZATION OF THE GENERAL SETTING IN
WHICH THE SPHS IS IMPLEMENTED
Basic Information - Honduras is a low income country located in Central
America with a total population of 6,941,000. It has undergone serious
macroeconomic problems since the 1980s, characterized by high
external debt, a low rate of growth, and extreme volatility of growth.
During the 1990’s, the country also suffered two major droughts and
two hurricanes which left a trail of destruction and loss in their wake.
Governance is problematic, as expressed in weak norms and institutions
and a limited capacity to bring about consensus and lead constructive
changes. Honduras suffers from a weak court system, problems with
conflict resolution, and poor citizen control over public policy and
management (IDB, 2002).
Economy - Honduras is the third-poorest country in the Western
Hemisphere after Haiti and Nicaragua. Its per capita income today is
lower in real terms than 20 years ago (IDB, 2002). Honduras is highly
dependent on foreign aid and this dependency has increased after
Hurricane Mitch hit the country in 1998.
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According to World Bank data, in 2004 the country’s GNI (Gross National
Income) was US$ 7.3 billion and the GNI per capita (Atlas method,
current US$) was US$1,030 (average GNI per capita for the LAC region
was US$ 3,600). Although the share of households living under the
poverty line decreased from 67.5% to 63.9% between 1993 and 2002,
households living in extreme poverty increased from 45.1% to 45.2% in
the same period (Instituto Nacional de Estadisticas (INE), 2002). Poverty
in Honduras is exacerbated by income inequality, which increased by 3%
between 1991 and 1998 (World Bank, 2004). In the rural areas, where
households are scattered throughout villages and remote mountainous
areas, 62.7% of the population lives in extreme poverty (World Bank,
2004), and a baseline survey executed by the IDB in 2000 found that
this figure was 70% in certain communities (IFPRI 2001). As of 2003, the
urban population reached 45.6% of total population, while rural settlers
were 54.4% of total population. While the unemployment rate is low
- 4.8 % in 2002 - 54.6% of working people had a job in the informal
economy and underemployment accounts for 35.9% of total employment
(INE, 2002). Low productivity and low salaries may be explained by the
low level of education among the working population, which has 5.3
years of education on average.
Health and Education - In 2003 the adult literacy rate (ages 15 and
above) was 80% and life expectancy at birth was 67.6 years. As of 2002,
68% of the total population had access to improved sanitation and 90%
of the total population had access to an improved water source (UNDP,
2005) although 47% of the population did not have access to a sewerage
system (PAHO 2004).
Because of the high levels of poverty and a large rural population, the
majority of Hondurans cannot afford doctors, drugs or transportation to
health care facilities. A very small percentage of Hondurans have access
to medical services. According to a study performed by PAHO/WHO in
2001, 56% of total population was excluded from access to health care.
The main causes of exclusion were deficits in infrastructure and medical
supplies (PAHO, 2004). The Garifunas, the main indigenous group, are
one of the country’s most excluded populations.
Other social indicators that negatively affect the performance of the
health services include the proliferation of marginal urban areas, an
increase in the population over age 60, and the fact that more than half
of the population is below the age of 19 (PAHO/WHO, 2001(b)). The
country also has weak coordination among providers in the public health
services network and insufficient coordination between the public and
private providers (PAHO/WHO, 2001(b)).
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Honduras’s Infant Mortality Rate has declined over the last decades,
following the regional trend. Much of the improvement occurred in a
short period in the mid-1990’s, when the IMR dropped from 50 deaths
per 1,000 live births to 42 (PAHO, 2004). The rate of decline seems
to have slowed, however, and in 2003 the IMR was 32 per 1,000 live
births. The prevalence of malnutrition/ low weight in children under five
years old was 17%. Between 1993 and 2001 coverage of the expanded
program of immunizations for children under one exceeded 95% for
some vaccines.
Between 1990 and 1997, the country’s maternal mortality ratio dropped
from 182 to 108, an impressive reduction in such a short period. Some
researchers suggest that this was the result of the cooperative relationship
developed between international donors and national health officials,
resulting in effective transfer of policy and institutionalization of the priority
of reducing maternal mortality within the country’s system (Shiffman et
al, 2004). In 2003 the maternal mortality ratio according to modeled
estimates was 110 per 100,000 live births and data for 2001 indicate
that 55.7% of births were attended by skilled health staff. In 2007, the
total fertility rate was 3.5 (CIA World Factbook), while the adolescent
fertility rate in 2004 (15-19) was 99 births for every thousand women
ages 15-19 (Global Health Facts, 2007). Adolescent pregnancy is one
of the main reproductive health problems in the country.
Although the country’s national public health system was created in
1959, when the Honduran Social Security Institute began to operate,
the expansion of health services in all regions of the country has been
very slow. In 1990 Sectoral Reform began within the context of state
modernization, but no agenda was set up for the reform. In 1999, as
part of the national reconstruction and transformation in the wake of
Hurricane Mitch, the “1999-2001 Policy Guidelines” were established to
meet the population’s health expectations with equity, quality, solidarity,
and citizen participation and to strengthen the health network and expand
coverage (PAHO/WHO, 2001(b)).
As of 2002 Honduras’s total expenditure on health as a percentage
of GDP had increased to 6.2%, from 5.6% in 1998. Government
expenditure on health in 2002 made up 51.2% of the total, and 41.6%
of total expenditure on health was out-of-pocket. The health care needs
of the population are generally met through public services provided by
the central and/or municipal government, autonomous State enterprises,
and private for-profit or non-profit entities. The Honduran population is
guaranteed a basic level of health protection; however, in practice, more
than 30% of the population does not receive it (PAHO, 2004). PAHO
also estimates that in 2001 83.1% of the population was not covered
by any type of insurance scheme and thus relies completely on public
institutions and non-profit private organizations.
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The public sector is comprised of the Ministry of Health and the Honduran
Social Security Institute (IHSS). The Ministry of Health has assumed the
steering and regulatory role for the social sector, formulating policies,
overseeing the operations of the agencies that make up the system,
and generally guaranteeing the constitutional right to health protection
(PAHO/WHO, 2001(b)). The IHSS is a decentralized institution that not
only collects and manages tax revenues from compulsory employees and
contributes to the health sector , but also engages in health promotion,
protection, and recovery activities in specific geographic areas through
care networks comprised of outpatient and hospital facilities.
Table 42: Honduras: general situation
Contextual factor
Health status
Deteriorates
Poverty Level
Improves
X
Education level
Hinders
X
Access to water/sanitation/electricity
X
Government’s institutional strength/fragility
X
Country’s governance
X
Unemployment Rate
X
X
X
X
X
X
X
3 . ANALYSIS OF THE PERFORMANCE OF THE SPHS
a). Has it increased equity in the access to/utilization of
health services?
The BMI has increased utilization of health resources and interventions,
the IDB reports. Vaccinations, pre-natal visits, and check-ups have all
increased (IDB, 2007). It is not clear that the BMI has increased equity,
however, nor that it has improved health status (see below). The BMI
has not yet reached all the eligible population in the targeted regions
because of lack of resources and inadequate distribution of vouchers.
Moreover, an evaluation performed by the IDB in 2002 found that 40%
of BMI beneficiaries in the poorest areas are in the two highest quintiles
(IDB, 2002).
102
Promotes
X
X
No. of rural dwellings/ remote settlements
Labor informality
Demand for health care
CASE STUDIES
b). Has it offset hindering social determinants?
Given its nature, it is expected that the BMI would contribute to offsetting
poverty. However, it is not clear that the program has achieved this goal,
given the widespread poverty existing in the country, the limited amount
of resources allocated to the program, and the problems faced in the
application of the program so far. In their evaluation of the programme,
the IDB argues that the amount of the money given to the families is too
small to induce changes on their consumption, given that it represents
less than 5% of the target population’s total spending (IDB, 2002). It is
noteworthy that similar conditioned cash transference programs implemented in Mexico and Nicaragua represent 20% and 18%, respectively,
of the eligible families’ total spending (IDB, 2002).
While two of the program’s four goals are related to malnutrition (to
reduce food insecurity and alleviate malnutrition during periods of economic adjustment) no significant changes were found in the caloric consumption of women and children participating in the program, and the
increase in protein consumption is lower than that achieved by other
programs (Bitran and Muñoz, 2000). This may be related not only to the
small amount of the voucher but also to the low frequency of delivery
(twice a year) which means the voucher cannot be incorporated in the
family budget on a regular basis (IDB, 2002).
A study carried out in 1995 showed that the BMI had an important and
positive impact on women’s education and thus promoted a greater demand for health services (Bitran and Muñoz, 2000)
Table 43: BMI’s performance: social determinants
Category
Performance
yes
no
Offsets poverty by eliminating or reducing economic barrier
X
Fosters women’s social status
X
Fosters health rights through Right Charts, explicit guarantees, etc.
X
Offsets unemployment/informal labor by eliminating or reducing economic barrier
X
Offsets women’s lack of education, fostering demand for health care
X
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c). Has it increased access to and coverage of technically
appropriate interventions by eliminating at least one
source of exclusion in health?
A study conducted in three regions of the country in 1992 found that the
utilization of health care and preventive services by children under five
years old increased dramatically between 1990 and 1991 (Bitran and
Muñoz, 2000). The author argues that this can be credited to the implementation of the BMI because health services utilization among similar
populations served by health facilities that were not providing the BMI decreased over the same period, while utilization by adults served by health
centers that did provide the BMI slightly increased. An evaluation conducted by the IDB in 2002 found that health services utilization and the
education of the mothers regarding health and hygiene had increased,
as have the number of well-child check-ups and the percentage of pregnant mothers that have 5 or more prenatal controls (IDB, 2004).
The BMI has increased its coverage over time, although many problems
with voucher distribution remain. Increasing the demand for health care
may be crucial to reducing maternal and child mortality, since one of the
most important components of prevention is timely and adequate recognition of illness and the subsequent demand for health care. In order to
achieve this goal and to reduce causes of exclusion, the program should
increase coverage and reach the most disadvantaged groups.
The BMI has not been given the highest priority regarding public social
spending, not even within PRAF. For example, according to the 2005
Honduras Government Report on the Poverty Reduction Strategy (ERP),
in the second semester of 2004 the total budget allocated to the area of
strengthening protection to specific groups was Lps. 166.6 million (US$
8.66 million), of which Lps. 139.7 million (US$ 7.3 million) was disbursed through PRAF. The BMI was assigned 10% of this budget, around
US$ 700,000 (Government of Honduras, Office of the President, 2005).
Moreover, the scheme’s dependency on extra-budgetary resources from
international cooperation agencies remains one of its main weaknesses
and threatens its sustainability over time.
One of the BMI’s goals is to foster health services utilization by introducing health-seeking behavior, so that health care will be demanded
when needed. In this sense, the BMI may be contributing to reducing the
cultural barriers that prevent the demand for health care. However, if the
BMI were to be fully applied all over the country and actually succeed in
reaching all eligible beneficiaries, the resulting increase in demand for
health services might pose serious strains on infrastructure as well as on
the human resources needed to meet that demand. The program’s low
coverage, a result of financial limitations, prevents this from happening
today.
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Table 44: BMI. Coverage and access
Category
Increases coverage (rise in number of people covered as a % of eligible population)
SPHS
yes
no
X
Establishes a single guaranteed portfolio of entitlements with the same quality, content, and
delivery conditions for all socioeconomic groups so as to avoid segmentation
X
Increases coordination/integration within the system so as to avoid fragmentation
X
Improves resource allocation and organization of health interventions by increasing number
and capabilities of human resources in previously underserved areas
X
Improves resource allocation and organization of health interventions by increasing the amount
of public spending allocated to the scheme
X
Public spending allocated to the scheme is progressive
X
Improves geographical distribution of the service delivery network and health infrastructure by
increasing number/amount of health facilities, equipment, medical devices, and drugs in previously underserved areas
X
Increases information system’s coverage
X
Increases access (number of people who access health goods or services provided by the
scheme)
X
Eliminates/reduces geographic barrier
X
Eliminates/reduces economic barrier
X
Eliminates/reduces gender barrier
X
Eliminates/reduces employment status barrier
X
Improves access to drinkable water, sewerage, roads and/or transportation
X
Improves refuse collection
X
d). Have health outcomes improved?
The IDB’s Office of Evaluation and Oversight reported in 2007 that the
health component of the PRAF-II had “no impact on incidences of stunting, diarrhea, or [mal] nutrition” (IDB, 2007). The BMI may be playing
a role in the decline of the Infant Mortality Rate but the program’s low
coverage makes it difficult to draw conclusions. The Maternal Mortality
Ratio has decreased significantly over the period 1990-2001, although
rates are still high and the rate of decline has slowed significantly. In
1990, there were 182 maternal deaths for every 100,000 live births,
falling to 108 in 1997 (Danel, 1999). The most recent figure for Maternal Mortality Ratio shows little change: it was estimated at 110 in 2000
(WHO, 2007).
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Graph N. 6
Maternal Mortality Rate under PRAF,
1990-2001
190
170
150
130
110
90
1990
1997
2000
Source: Danel 1997 and WHO 2007.
Table 45: BMI’s performance
Goal
106
Performance
Increase equity in the access to and/or utilization of
health services
No. An important share of the beneficiaries are in the
highest quintiles
Offset social determinants that hinder demand for
health care and/or hamper health status
It seems to offset mother’s lack of education
Increase access to and coverage of technically appropriate interventions by reducing or eliminating at
least one cause of exclusion
It helps reduce the economic barrier
CASE STUDIES
5.6
OPORTUNIDADES Program -MEXICO-
1 . CHARACTERIZATION OF THE SPHS
Mexico’s Programa de Desarollo Humano OPORTUNIDADES (originally named Progresa and now known as OPORTUNIDADES) is a cash
transfer scheme designed to encourage families to invest in the health,
nutrition, and education of children. A financial payment is made to the
female head of the household and is conditional, among other things,
on the family’s registration at the nearest health post; their utilization of
health services, especially those for pregnant women, lactating mothers,
and children under 5; and the head of household’s monthly attendance
at community health classes (OPORTUNIDADES, Reglas de Operación
2007). The program covers a large spectrum of benefits, including those
for senior citizens and students through college, but this analysis focuses
on the maternal and child component of the scheme.
Progresa/OPORTUNIDADES was designed to tackle the country’s stubbornly high poverty rate and to replace a set of food subsidies and other
poverty programs that were widely considered to be ineffective. It expanded rapidly; in 2002 the program, which was originally implemented
in the poorest rural areas of the country, had been implemented in 31
states. Funds allocated to the program grew accordingly, from US$34
million in 1997 to US$3.6 billion in 2007 (Sedesol, 2007). The size of
the cash transfer is large, and overall these payments represent around
20% of the participating families’ income (Coady, 2003; IDB, 2002).
Currently the program serves about 5 million families, a group of beneficiaries that is about 25% of Mexico’s total population, 50% of its poor
population and almost 100% of its extremely poor population (Sedesol,
2007).
The program ensures progressive spending by using three levels of targeting to select beneficiaries. First, the government determines the general
geographical areas in which the program will be implemented, based
on a development index that considers income level, population density,
and access to health and education. Villages within these areas are given a community poverty score based on information about educational
level, occupation, and housing conditions available from national census
data. Finally, poor families within those villages are selected on the basis
of data about factors closely associated with income, collected through
a special community census. There is no application procedure; families
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CASE STUDIES
e informed about the program and about their eligibility.18 The benefit
is valid for three years but is conditional on meeting the requirements
stipulated by the program. After three years, the families are reviewed to
determine whether they are still eligible. If they still meet the socioeconomic criteria for the program the benefit is renewed. The program covers a large spectrum of benefits, including those for senior citizens and
students through college, but this analysis focuses on the maternal and
child component of the scheme.
OPORTUNIDADES requires mothers to seek preventive care, such as prenatal care, well-baby care, child immunizations, growth monitoring for
children 0-5 years old, and adult preventive check-ups. Pregnant women
are required to have five prenatal visits in the first three months of pregnancy, and children less than 24 months must be monitored for growth
and immunization every two months. Lactating women are also required
to have two visits per year for nutritional monitoring. Besides cash, the
program also offers free food supplements to all pregnant women and
children under the age of 2, as well as to children under 5 who show
signs of malnutrition.
Funding for OPORTUNIDADES comes from general taxes and the IDB
and World Bank.
Table 46: Main features of OPORTUNIDADES
Feature
Category
Type
Conditioned cash transfer
Mode of financing
Publicly funded social assistance
Source of funds
General taxes
Other revenues: extra-budgetary sources: IDB, World Bank
Risk pooling arrangement
Income-based
Management and management
level
Ministry of Social Development, with the assistance of the Ministries of
Education and Health at national, sub national and local level
Degree of selectivity
Targeted: pregnant or breast feeding women, children under 5 years of
age from poor families
Who is entitled to coverage
Family
Condition for access
Means tested specific attribute: proof of income/age/proof of childbirth/proof of pregnancy
Extend of risk pooling
Small pool
Explicit portfolio?
Explicit
Degree of coverage
Complementary
Provision
Public
18. When implementation of the program first began in the rural areas, eligibility requirements were reviewed by the community,
which could nominate the excluded families in event of an obvious targeting error. A process of certification of eligibility would
then take place. In urban areas, eligibility was based on self-selection due to the high costs of undertaking a census prior to
the implementation of the program.
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CASE STUDIES
2 . CHARACTERIZATION OF THE GENERAL SETTING IN
WHICH THE SPHS IS IMPLEMENTED
Basic Information and Demographics – Mexico is an upper-middle income country, consisting of 31 states and more than 2,438 municipalities. According to the 2005 census, its population is about 103 million
(INEGI, 2005). The majority of the population - 75.5% - is concentrated
in urban areas, with nearly one-third of the population living in five of
the thirty-two metropolitan areas in Mexico (UNDP-HDR, 2005). Mexico
is characterized by great socioeconomic and ethnic diversity both within
and between regions and states. This diversity is a permanent source of
social conflict and has triggered several political crises along the history
of the country (World Bank, 2005; UNDP-HDR, 2005). Significant inequality between city and village persists, with the rural areas - populated
mostly by indigenous groups - showing worse indicators for almost all
aspects of social development including health, education, employment,
income, and access to basic services. In 2004, one out of three rural
residents was living in extreme poverty, compared to one out of ten urban
residents (World Bank, 2006).
Governance - General elections in Mexico in 2000 ended 70 years of
the Institutional Revolutionary Party (PRI)’s rule, and the one-party political system was replaced by a multi-party one. Although this process
is considered an important democratic leap forward, governance has
significantly weakened over the last years, overshadowing democratic
gains. Some authors argue that protests against government policies and
labor strikes increased dramatically during the administration of Vicente
Fox.19 Drug-related violence has also increased over the past several
years (Power and Interest News Report, 2006).
Economy – Mexico’s GDP grew by 4.8% in 2006, to over 1.1 trillion US
dollars (PPP), and the 2005 GNI per capita was 10,560 dollars (PPP),
the second highest in Latin America. However poverty in the country remains high, and as of 2003, an estimated 40% of population lived on
less than US$ 2.00 a day, of which 9.9% lived with less than US$ 1.00 a
day (UNDP-HDR, 2005). The Ministry for Social Development estimates
that 17% of the population lives below the food poverty line (or pobreza
alimentaria in Spanish) – that is, they can’t afford to fulfill their basic
nutritional needs (Cruz, de la Torre, Velázquez, 2006). According to the
Ministry for Social Development, 50 million Mexicans (about 50% of the
population) live in poverty, with half of those living in extreme poverty,
or what the government calls “pobreza de capacidades.” 20 This figure
does represent an improvement over the 64% poverty rate the country
experienced following the 1994-1995 financial crisis.
19. Mexico elected a new president, Felipe de Jesús Calderón Hinojosa, in December of 2006.
20. Pobreza de capacidades is defined as living on two dollars or less a day in rural areas and less than three dollars a day in
urban areas (Sedesol, 2007).
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CASE STUDIES
Unemployment decreased from 3.7% in 1997 to 2.5% in 2003, a period during which the number of jobs in the maquiladora industry grew
significantly (UNDP-HDR, 2005). However, 61.8% of the total employed
persons in Mexico work in the informal economy (Negrete R., 2001),
and real wages for the urban poor have decreased by 5% since 1991.
Real wages have fallen mainly in the self-employment sector, where the
poor are disproportionably represented. Real wages for the extreme poor
who are self employed and do not own capital had fallen by 22% as of
2003 (World Bank, 2006). Real incomes for workers in Mexico’s manufacturing sector declined by a cumulative 2.6% between 1995 and 2005
(World Bank, 2006).
Health - Life expectancy at birth in 2003 was 75.1 for both sexes, and
the adult literacy rate (% of those aged 15 and above) was 90.3 (UNDPHDR, 2005). Fertility rates have declined from 2.7 in 1997 to 2.2 in
2007 (Consejo Nacional de Población, 2006), but the average number
of children per woman in rural areas is still high (2.3 versus 1.4 in urban
areas). As of 2002, 77% of population had access to improved sanitation and 91% had access to an improved source of water (UNDP-HDR,
2005).
The health system in Mexico is comprised of three main sectors: Social
security, the public sector under the Ministry of Health and the private
sector. The Social Security sector covers formal workers and includes the
Mexican Social Security Institute (IMSS), the Social Security and Services
Institute for State Workers (ISSSTE), Petróleos Mexicanos (PEMEX), the
Armed Forces (SEDENA) and the Navy. The Ministry of Health covers the
uninsured population in rural and urban areas. In 2003, the government
created the System of Social Protection in Health (SPSS), which established the Seguro Popular. Through a resource allocation by the central
government and the states, the Seguro Popular provides health insurance
for a basic package of health services to families and citizens that, due to
their employment and socioeconomic condition, are not covered by the
Social Security institutions.
The Mexican health system is characterized by high degrees of segmentation and fragmentation, with a number of different health care provision programs co-existing without any integration and often representing
the conflicting interests of different political forces. This produces huge
inefficiencies in the provision of health services. In 2005, the social security institutions covered 55 million salaried workers in the formal sector, representing a decrease of 2.56% from 2000, due to a variation in
the unemployment rate from 2.2% in 2000 to 3.75% in 2005. Informal
workers, the rural uninsured population, and the unemployed account-
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CASE STUDIES
ed for 45 million people in 2005. They received care from the Central
Government’s Secretary of Health and the States Secretaries of Health,
which oversee public hospitals and clinics. There are huge differences
between the states in terms of their availability of per capita resources to
provide health services, and there are access problems for those in rural
areas (PAHO, 2007).
In 2004, the under five mortality rate in México was 22.9 per 1.000 live
births, high when compared to other upper-middle income countries in
the region, such as Chile and Uruguay (PAHO, 2005). The maternal
mortality ratio, according to modeled estimates, was 83 per 100,000
live births in 2003 (World Bank, 2003). This figure fell to 60 per 100,000
live births in 2005, according to estimates made by WHO/UNICEF/UNFPA/World Bank (WHO, 2008). Mortality rates differ widely from state
to state, with the Federal District, Puebla, Oaxaca, and Chihuahua registering higher rates than other departments. Mortality from preventable
diseases is high, especially in the southern region, including deaths from
malnutrition, common infections, and diseases associated with pregnancy and childbirth (PAHO, 2002). Mortality rates are especially high
among the country’s 63 indigenous groups, whose IMR is 58% higher
and MMR three times higher than that of the non-indigenous population
(PAHO, 2007).
Table 47: Mexico’s general situation
Contextual factor
Deteriorates
Poverty
Demand for health
care
Health status
Improves
X
Hinders
Promotes
X
Education level
X
X
Rural dwelling/ remote settlements
X
X
Access to water/sanitation/electricity
X
Government’s institutional strength/fragility
X
Country’s governance
X
Unemployment
Labor informality
X
X
X
X
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CASE STUDIES
3 . ANALYSIS OF THE PERFORMANCE OF THE SPHS
a). Has it increased equity in the access to/utilization of
health services?
OPORTUNIDADES has a very strong evaluation component that aims
to assess the program’s impact using both qualitative and quantitative
methods. The evaluation allows for any necessary adjustments on the
program’s design and execution and assists in the tracking of the program’s objectives and goals. Yearly evaluations have been performed
since 1999.
Early small studies found excellent results for the targeting system in place
for OPORTUNIDADES, but outcomes may have become less progressive
as the program was scaled up. Household surveys executed immediately
before and two years after its initiation, in approximately 300 villages that
had received services and 200 villages that had not, found that almost
60% of people reached by OPORTUNIDADES belonged to the poorest 20% of Mexico’s population, with 80% of beneficiaries were in the
two lowest quintiles (Bitran and Muñoz 2000). The study attributed these
highly progressive outcomes to the selection of poor villages and the
linkage of benefits to education/health program participation by children
(since the poor have more children than the better-off). But a more recent
World Bank study found that only 30% of the program’s beneficiaries
were in the first quintile of income, and only 60% were in the lower two
quintiles (Lindert, 2005). Still, those in the lowest quintile receive nine
times the benefits of those in the highest (Lindert et al. 2005). This area
of OPORTUNIDADES’ operation would benefit from further study.
A 2004 study of the effect of OPORTUNIDADES found a highly significant
(50%) increase in the demand for check-ups in towns where the program
was in place compared with towns where it was not (Bautista, 2004).
Bautista also showed a sharp increase in curative visits after the implementation of the program, which eventually leveled off while preventive
visits increased, implying that better preventive care had decreased the
need for curative care. Public health clinics received double the visits than
private facilities, and the program increased utilization of health services
for all age groups, except for children 0-2 years old (Gertler, 2000).
Gertler hypothesizes that OPORTUNIDADES must have had a positive
impact on preventing illnesses for this age group, resulting in a lower
number of visits. The evaluation also shows an increase in monitoring
for malnutrition and that OPORTUNIDADES children between the ages
of 0-5 have a 12% lower chance of getting ill than children who are not
receiving the benefit.
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CASE STUDIES
Since the program has been functioning in rural areas for a longer period, less attention has been paid to its impact on urban areas. Short-term
results, though, are equally promising. An external evaluation found that
urban families incorporated into the program increased their demand
for health services by more than 25% compared to those who were not
included. There were slight gains in the proportion of births attended by
qualified personnel (Cruz, de la Torre, Velázquez, 2006).
b). Has it offset hindering social determinants?
Results to date indicate that the program has been successful in ameliorating poverty among the participant families. An evaluation conducted
by the International Food Policy Research Institute in 2000 found that after
three years of implementation, OPORTUNIDADES had reduced poverty
by 8% in areas that benefit from the program when compared to those
that do not. An important reason for this is the size of the cash transfer,
which represents a 20% average increase in the income of households
living in extreme poverty. Moreover, Hoddinott and Skoufias found that
70% of the cash transfer had been used to increase food availability in
the household both in terms of quantity (calories) and quality (proteins
and micronutrients) (Hoddinott and Skoufias, 2000).
But the reduction in poverty may not be equitable. One study found that,
though the household income of incorporated families did rise over the
period 1997-2002, the largest increase was among those households
that had been the best off to begin with (Rubalcava and Teruel, 2003).
These results were echoed in the findings of Fuentes and Soto, who discovered that height in children under five was positively correlated with
educational and income level of the father, leading them to speculate
that those families that are less poor are better able to navigate the
program (Fuentes M. and Soto H., 2003). And there appears to be little
relation, at least in the short term, between percentage of families incorporated into OPORTUNIDADES and poverty reduction at the state level
(Parker and Scott, 2001).
OPORTUNIDADES, in an attempt to offset the negative effect on health
of women’s low status, has an explicit gender focus. The program engages with gender in three ways:
1) it gives the financial transfers specifically to the female head of
the household
2) beginning at the secondary school level, the transfers associated
with school attendance are higher for girls than for boys
3) it offers special health care benefits for pregnant and lactating
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CASE STUDIES
mothers
Women participating in the program have become more likely to determine on their own how to use their extra income from OPORTUNIDADES
and have developed more awareness, confidence and control over their
activities. Results from focus groups showed OPORTUNIDADES has
promoted recognition of the contribution and role of women in caring
for their families (Wodon Q., De la Briere B., Siaens C., Yitzhaki S.,
2003). Results are more mixed when it comes to more important decisions. Although Wodon et al. found that OPORTUNIDADES decreased
the probability that husbands made decisions alone in five out of eight
decision-making categories, a similar focus-group study saw little impact
on decision-making outside of the management of daily household affairs (Adato M. and D. Mindek, 2003).
Table 48: Performance of OPORTUNIDADES: social determinants
Category
Performance
yes
Offsets poverty by eliminating or reducing economic barrier
X
Fosters women’s social status
X
Fosters health rights through Right Charts, explicit guarantees, etc.
X
Offsets unemployment/informal labor by eliminating or reducing economic barrier
X
Offsets women’s lack of education, fostering demand for health care
X
c). Has it increased access to and coverage of appropriate
interventions by eliminating at least a source of exclusion from health care?
Skoufias and McClafferty’summary of evaluations of the program (2001)
found that attendance at health visits by children under 6 years of age
was 50% higher in the beneficiary population. According to recent studies, this proportion has risen over the period of the program’s implementation (Hernandez M. et al, 2006).
OPORTUNIDADES has not been as successful in the area of maternal
and pre-natal care. Skoufias and McClafferty’summary of evaluations of
the program reports an 8% increase in clinic visits by pregnant women in
their first trimester (Skoufias and McClafferty, 2001). However, Bautista
reports that pre-natal check-ups actually fell in both participating and
non-participating clinics between 1996 and 2002. OPORTUNIDADES
clinics even saw a greater drop (50%) in consultation in those clinics that
114
no
CASE STUDIES
were not incorporated into the program (Bautista, 2004). The program
does seem to have increased access to quality pre-natal care (measured
by time of first pre-natal check-up, number of total pre-natal visits, and
actions performed during those visits) in rural areas. But it has not succeeded in increasing the proportion of births attended by trained personnel in rural areas, which has actually fallen compared to the percentage
among women not incorporated into OPORTUNIDADES (HernándezPrado et al., 2005). Results are similar in urban areas: women incorporated into the program are significantly less likely (either than those
eligible but not incorporated, or those not eligible) to have attendance by
qualified medical personnel at the birth and/or to give birth in a medical
setting (Hernández-Prado et al., 2005).
Ochoa and Garcia, based on an evaluation performed in the state of
Chiapas, found few, if any, significant improvements in access to interventions among beneficiaries of the program, and often discovered that
non-beneficiaries who have access to different systems of free health
care, were more likely to demand care beyond those interventions that
are prerequisites for receiving the cash transfer (Ochoa and Garcia,
2005). The main explanation given for these unexpected results was the
poor quality of the health care offered under OPORTUNIDADES. Ochoa
and Garcia argue that the impact of the program on health equity will be
limited unless it is associated to a substantial improvement of the health
services provided by the health providers (Ochoa and Garcia, 2005).
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CASE STUDIES
Table 49: OPORTUNIDADES: Coverage and access
Category
Increases coverage (rise number of people covered as a % of eligible population)
SPHS
yes
X
Establishes a single guaranteed portfolio of entitlements with the same quality, content, and
delivery conditions for all socioeconomic groups so as to avoid segmentation
X
Increases coordination/integration within the system so as to avoid fragmentation
X
Improves resource allocation and organization of health interventions by increasing number
and capabilities of human resources in previously underserved areas
X
Improves resource allocation and organization of health interventions by increasing the amount
of public spending allocated to the scheme
X
Public spending allocated to the scheme is progressive
X
Improves geographical distribution of the service delivery network and health infrastructure by
increasing number/amount of health facilities, equipment, medical devices, and drugs in previously underserved areas
X
Increases information system’s coverage
X
Increases access (rise in number of people who access health goods or services provided by
the scheme)
X
Eliminates/reduces geographic barrier
X
Eliminates/reduces economic barrier
X
Eliminates/reduces gender barrier
X
Eliminates/reduces employment status barrier
X
Improves access to drinkable water, sewerage, roads, and/or transportation
X
Improves refuse collection
X
d). Have health outcomes improved?
Gertler found that children under 5 who were participating in the program had a 25% lower incidence of illness than their non-participating
peers and suggested that morbidity rates drop the longer a child stays
in the program (Gertler 2004). Infant mortality was also 2% lower in
towns that were incorporated into OPORTUNIDADES (Hernández B. et
al., 2005). This may be related to the finding that the program produced
declines in levels of child malnutrition as measured by children’s weight
by height: participating children between 1 and 3 years of age experienced a 16% increase in their annual growth when compared to nonparticipating children (Behrman and Hoddinott, 2000). This effect seems
to be progressive: incorporation into OPORTUNIDADES was positively
associated with better growth among the youngest and poorest children.
116
no
CASE STUDIES
The average height of this group (children under 6 months old and living in the poorest households) was 1.1 cm greater, even when adjusted
for age and size at birth. OPORTUNIDADES was also associated with
lower rates of anemia in low income, rural infants and children (Rivera J.,
Sotres-Alvarez D., Habicht J., Shamah T., Villalpando S., 2004).
The program seems to have had a positive effect on maternal mortality as well. The most recent major study, which was performed in 2003,
found an 11% reduction in maternal mortality in villages that had households incorporated into the program, as opposed to those villages with
no incorporated homes. This effect was strongest in areas of medium
and very high marginalization, but it did not rise proportionately with the
percentage of people incorporated into the program (Hernández B. et
al., 2005).
Table 50: Performance of OPORTUNIDADES
Goal
Performance
Increases equity in the access and/or
utilization of health services
Yes. The majority of beneficiaries are poor.
Offsets social determinants that hinder
demand for health care and/or hamper
health status
It has helped to offset poverty. The size of the cash transfer represents a 25% increase in income of extremely poor households. It
has fostered the demand for health care among mothers. It fosters
social status of women within the family and promotes girls’ attendance at school.
Increases access to and coverage of
appropriate interventions by reducing
or eliminating at least one cause of
exclusion in health
It has contributed to removing economic barriers. It has increased
access to health care interventions. It has not increased coverage
of appropriate interventions
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CASE STUDIES
5.7
Integrated Health Insurance (SIS) PERU
1 . CHARACTERIZATION OF THE SPHS
The Integrated Health Insurance (Seguro Integral de Salud, SIS) is part
of a larger strategy of the Ministry of Health, in line with the recommendations set by major international donors, to reduce high mortality
rates by eliminating the economic, cultural, and informational barriers
that prevent the poorest households from accessing health services. SIS
was created in 2001 by integrating two preceding initiatives: the Mother
and Child Insurance (Seguro Materno-Infantil, SMI) and the Free School
Health Insurance (Seguro Escolar Gratuito, SEG).
The SEG was created in 1997 to benefit school children from 3 to 17
years of age. It covered accident- and disease-related health care services, which were provided in public facilities. Initially designed as a pilot
project, President Fujimori ordered its implementation nationwide (Holst,
2005).
The SMI was designed to support public health priorities that focused
on pregnant women, new mothers and children 0-4 years of age. It was
created in 1998 and functioned as a demand subsidy that financed the
costs of health services as they were needed. It was initially implemented
in two pilot zones of the country and expanded to five other departments
in 1999 (Jaramillo and Parodi, 2004). The SMI covered women, during pregnancy and postpartum, and all children from childbirth until 4
years old, whenever they were not affiliated to other health insurances,
public or private. The SMI only covered the population of the departments where it was implemented. It insured against the main illnesses
and risks associated with pregnancy, and included periodic monitoring
of the pregnancy, natural births and c-sections, monitoring of postpartum, nutritional deficiencies, and oral health. In the case of children, the
insurance covered child developmental screening and growth monitoring, immunizations, diarrhea, and respiratory infections. The estimated
beneficiary population for the period 1999-2001 was 718,121 persons
(Jaramillo and Parodi, 2004). No law regulated the creation of the SMI.
Although the SMI was directed at low income groups, usually from the
informal sector, its benefits did not reach the target population. Coverage of the SMI was low, and only 33% of the population was affiliated
to the program. When this figure was disaggregated by socioeconomic
level, the SMI showed a regressive pattern. Only 25% of those affiliated
to the SMI belonged to the lowest quintile, while affiliation in the highest
quintile was 37%, according to an ENDES 2002 survey. In other words,
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CASE STUDIES
nearly 1 in every 3 people that used the services of the SMI was not poor
(Jaramillo and Parodi, 2004).
The Group for the Analysis of Development’s (GRADE) evaluation of the
SMI found that (GRADE, 2004):
1. The SMI improved access to health care for mother and child
populations, but the impact on equity was negative. The SMI
had a significant impact only in the top quintile.
2. The report found that when the government tried to increase
coverage and access to health care, the poorest were not the
ones that most benefited from this increase. Targeting errors resulted in substantial leakage and undercoverage.
The SIS expanded on its predecessor’s coverage in geographical and
population terms (Holst, 2005). To achieve better results and differentiate
itself from previous programs, the SIS was based on three Health Plans
(Vera de la Torre, 2003):
- Plan A, for children 0-4 years of age
- Plan B, for children and teenagers 5-17 years of age
- Plan C, for pregnant women
Two more health plans were added later on, expanding coverage to other highly vulnerable population groups:
- Plan D, aimed at providing coverage of emergency services for adults
- Plan E, aimed at certain sectors of the adult population
Four other population groups were incorporated as beneficiaries by political decision and without following any enrollment criteria (Vera de la
Torre, 2003):
- Popular dining facilities (“comedores populares”) leaders
- Mothers of children who are beneficiaries of the Supplementary Food
Program (“El vaso de leche”)
- Mothers who work at public day care facilities (“Wawa wasi”)
- Women who are members of Local Health Management Committees
(Comités de gestión)
- Shoe shiners
In 2007 SIS began to reorganize its structure and functions in response
to the mandate of extending the insurance scope, established by the
Supreme Decree 004 2007. This Decree modifies the current insurance
plans (focused on pregnant women, children, adolescents, and emergen-
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CASE STUDIES
cy care) extending SIS’s coverage to all the uninsured population through
two components: the subsidized component aimed at the poor (1st and
2nd income quintiles) and the semi-subsidized component focused on
the population with limited ability to pay (3d income quintile). SIS also
made official its List of Prioritized Sanitary Interventions (Listado Priorizado de Intervenciones Sanitarias LPIS), which includes a comprehensive
set of preventive, curative and rehabilitation health care interventions.
The List was created based on the existing information regarding the
main health interventions available in the country. It may be expanded,
modified, and adapted depending on SIS’s budgetary situation and always in an incremental fashion, according to health priorities at national
and sub-national level and to cost-effectiveness criteria.
Financial resources for the scheme come from the National Treasury.
Most of the funding comes from general taxes. The Ministry of Health
earmarks a certain amount to cover the budget and to finance the benefits (Holster, 2005). Funds from the IDB, the World Bank and bilateral
agencies such as the Belgium Cooperation Agency also contribute to
financing the scheme. The annual budget allocated to SIS has increased
from 316,000,000 PEN (US$106,485,865)21 in 2007 to 471,124,352
PEN (US$158,759,760) in 2008. This represents a 50% increase in real
terms. (Belgian Cooperation Agency, 2008)
21.
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Exchange rate: 1 US$ = 2,96753 Peruvian Nuevo Sol
CASE STUDIES
Table 51: SIS. Benefit Plans
Plan
Plan A
Plan B
Plan C
Plan D
Plan E
Covered population
Children 0-4 years of
age
Children and teenagers
5-17 years of age
Health Package
• Preventive health services
• Diagnosis and treatment
of common illnesses
• Care of children born
with HIV-AIDS
• Emergency transportation
services
• Funeral expenses
• Diagnosis and treatment
of common illnesses
• Emergency transportation
services
• Funeral expenses
Services covered
• Immediate care for healthy newborns
• Hospitalization for newborns with
pathologies
• Well-child check-ups
• Low-weight newborns check-ups
• Emergency care
• Drugs
• X Rays and other imaging services
• Laboratory
• Surgery
• Dental services (hygiene, restoration, treatment, extraction)
• Transfer
• Burial expenses
•
•
•
•
•
•
•
Check-ups
Emergency care
Drugs
X Rays and other imaging services
Laboratory
Surgery
Dental services (hygiene, restoration, treatment, extraction)
• Transfer
• Burial expenses
Pregnant women
• Prenatal care
• Institutional normal and
high risk delivery
• Postpartum care (up to
42 days after delivery)
• Diagnosis and treatment
of other health problems
• Emergency transportation
services
• Funeral expenses
Adults’ health emergencies
• Immediate emergency
care
• Emergency transportation
services
• Funeral expenses
•
•
•
•
•
•
•
Emergency care
Drugs
X Rays and other imaging services
Laboratory
Surgery
Transfer
Burial expenses
• Health care
• Emergency transportation
services
• Funeral expenses
•
•
•
•
•
•
•
•
Medical check-ups
Emergency care
Drugs
X Rays and other imaging services
Laboratory
Surgery
Transfer
Burial expenses
Targeted Adult
•
•
•
•
•
•
•
Medical check-ups
Emergency care
Drugs
X Rays and other imaging services
Laboratory
Surgery
Dental services (hygiene-restoration treatment-extraction)
• Transfer
• Burial expenses
SOURCE: Vera de la Torre, 2003; World Bank, 2006
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CASE STUDIES
Like the SMI and SEG, the SIS operates as a demand subsidy, reimbursing health providers when they supply to SIS beneficiaries those services
that are included in SIS benefits. It is noteworthy that payments are not
prospective but rather are reimbursements for services already provided.
The SIS relies on public providers for service delivery, using the Ministry of
Health’s existing human resources and infrastructure. NGOs, Social Security, and private providers are not allowed to participate in the scheme
as providers. Only in special cases was a patient referred to a nonpublic
facility. Services are provided at the following levels:
•
•
•
Health posts and centers (urban and rural): services include primary health care, immunization, pharmacy, obstetrics/gynecology,
and basic dental services, with a few facilities undertaking lab diagnosis.
First and Second Level Hospitals: basic health care specializations,
such as internal medicine, surgery, pediatrics, and gynecology.
Larger hospitals offer additional specializations such as cardiology, gastroenterology, traumatology, neurology, etc.
Third Level: represented by the Institute for Child Health and the
Maternal and Perinatal Institute; both institutes offer high-complexity treatments such as neonatology, neurosurgery, etc, and are
equipped with intensive care units, scanners, ultrasounds, x-rays,
and complex lab diagnosis.
By December 2005 the SIS covered 11,026,607 people, amounting to
around 39.5% of total population (Ministry of Health, 2006).
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CASE STUDIES
Table 52: Main features of the SIS
Feature
Category
Type
Free primary health care provision and Free maternal and child care
Mode of financing
Publicly funded health programs
Source of funds
General taxes
Other revenues (extra-budgetary sources: IDB, World Bank, Belgian
Cooperation Agency)
Risk pooling arrangement
Income-based
Management and management level
MoH at national/sub-national/local level
Degree of selectivity
Targeted; poor population belonging to the specific segments: pregnant or breast feeding women, children 0-17 years of age, adults in
health emergency situations, targeted adults
Who is entitled to coverage
Individual
Condition for access
Means tested specific attribute: proof of income/age/proof of childbirth/proof of pregnancy
Extend of risk pooling
Large pool
Explicit portfolio?
Explicit
Degree of coverage
Complementary
Provision
Public
2 . CHARACTERIZATION OF THE GENERAL SETTING IN
WHICH THE SPHS IS IMPLEMENTED
Basic Information - Peru is a lower-middle income country located in
the western part of South America, with an estimated total population
of 28.3 million as of July 2006, distributed across three major geographical regions: the coast, the Andean plateau and the Amazon forest
(UNDP-HDR, 2006). GDP per capita is around US$ 2,000, but there are
huge inequalities in income distribution. By 2000, 72.8% of the population lived in urban settlements. Regarding access to water and sanitation,
77 % of population had access to an improved source of water and 76%
had access to adequate sanitation in 2000 (UNDP-HDR 2002). Adult
literacy rate (% of people ages 15 and over) was 87.7% by 2004 (World
Bank, 2006).
Although Peru is a multiethnic country with nearly half of its population
of indigenous origin, a small elite of Spanish descent controls most of
the wealth and political power, while indigenous Peruvians are largely
excluded from both and make up for many of the population groups that
live in poverty (BBC News, 2006). The country is deeply divided political-
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CASE STUDIES
ly and economically and in its recent past it has alternated between democracy and military dictatorship. In the 1980s and 1990s Peru endured
a brutal war between government forces and Maoist rebels in which as
many as 69,000 people were killed (BBC News, 2006). The country has
been facing a strong governance crisis for for the last twenty years, with
very low government approval rates. During 2000 and 2001, Peru was
embroiled in a turbulent but peaceful political controversy. A corruption
scandal ended Alberto Fujimori’s third term as President and ushered in
a transitional government which ruled the country until Alejandro Toledo
was elected to the Presidency in July 2001 (World Bank, 2006). In 2006,
Alan García was inaugurated as the new President of Peru.
Economy – According to the National Household ENAHO 2004-2007,
poverty in the country fell from 48,6% of population living under the
poverty line to 39,3% between 2004 and 2007. Extreme poverty decreased from 17,1% in 2004 to 13,7% in 2007 (ENAHO, 2007). The
same source informs that both poverty and extreme poverty are highest
among indigenous people living in rural areas in the mountainous region
of the country.
According to the International Labor Organization ILO, Peru reduced its
urban unemployment rate from 10.1% in the third trimester of 2005 to
8.7% in the same period in 2007 (ILO, 2007). This figure means that unemployment in the country is lower than in Argentina, Brazil, Colombia,
Ecuador, Uruguay and Venezuela when compared in the same period
of time, but higher than the Region’s average of 8,5%. One of the most
pressing problems in the country is the lack of decent employment.22 Data
of the Ministry of Labour shows that underemployment in the country
reaches 65% and between 65% and 70% of the total employed population works in the informal economy. Moreover, between 2006 and 2007
the urban unemployment rate decreased for men but it did not change
for women, which means that the gender unemployment gap increased.
The labour market conditions contribute to increase migration to other
countries. Data of the Direction of Migration and Naturalization indicate
that an average of 1,150 Peruvians (210 thousand in all) traveled legally
or illegally to other countries in the first semester of 2006, which represents an increase of 39% when compared to the same period in 2004.
Health and Education - Maternal and child mortality rates in Peru are
among the highest in South America. Although maternal mortality has
declined in the past ten years, the maternal mortality ratio (MMR) remains
high at a reported 164 deaths per 100,000 live births (Ministry of Health,
Peru, 2002), with the WHO reporting the far higher figure of 410 (WHO,
2007). This high figure still hides geographic disparities, with some low-
22. According to ILO, decent work can be defined as “productive work in adequate conditions of freedom, equity, security and
dignity, in which rights are protected and has adequate salary and social protection”
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CASE STUDIES
income rural regions reporting an MMR of over 500 per 100,000 live
births (Ministry of Health, 2001). Underlying the high mortality is the
fact that institutional deliveries remain low in Peru, because the country
continues to lag behind its neighbors in the coverage of basic clinical
interventions. In 2000, 59.3% of total deliveries were attended by skilled
staff in the country, whereas almost 75% of deliveries in rural, low-income communities occurred in non-institutional settings (World Bank,
2006; USAID, 2005). Under-five mortality and infant mortality rates have
improved significantly and they were 29.2 and 24 per 1,000 by 2004
(UNICEF, 2006). However, despite these improvements they remain high
for a country of Peru’s income. Further decreases in infant and child mortality will require a focus on perinatal mortality, since this has increased
relative to other causes of infant mortality (World Bank, PID 2006).
As in most of the countries in the region, the health system in Peru is
highly fragmented and segmented. Two subsystems provide health services: the public sector, comprised of the Ministry of Health and the Social
Security System; and the private, made up of for profit providers (clinics,
physician’s offices, etc) and non-for-profit providers (NGOs). The Ministry of Health (MINSA) steers the health sector, drafts health policies, and
provides services to the poor population who cannot afford insurance;
social security (Seguro Social de Salud de Perú- ESSALUD) covers workers in the formal sector; and the private sector provides services to those
in the general population who can afford it.
There are four main health insurance schemes in Peru: ESSALUD, which
covers formal workers and their families; the insurance for the armed
forces and the police; private insurance; and the Integrated Health Insurance (SIS). According to a 2002 survey by the Instituto Nacional de Estadística e Informática (INEI), only 30% of Peru’s population was covered
by ESSALUD and half of the population was not covered by any insurance
scheme.
Inequality in the access to health care as well as in health outcomes
remain a top concern in Peru. Among the eight Latin American countries
for which there is a demographic and health survey (Bolivia, Brazil, Colombia, Dominican Republic, Guatemala, Haiti, Nicaragua and Peru),
Peru has the greatest inequality in infant mortality (World Bank, 2006).
Moreover, by 2003 40% of the population was excluded from access
to health care, with poverty and living in a rural settlement the strongest
predictors of exclusion (PAHO, 2003). Geographic inequalities in access
to health care continue to lead to poor health outcomes compared to
other countries in the region.
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CASE STUDIES
Table 53: Peru’s general setting
Contextual factor
Health status
Deteriorates
Poverty Level
Demand for health care
Improves
X
Hinders
Promotes
X
Education level
X
X
No. in Rural dwelling/ remote settlements
X
X
Access to water/sanitation/electricity
X
Government’s institutional strength/fragility
X
Country’s governance
X
Unemployment Rate
Labor informality
X
X
X
X
3 . ANALYSIS OF THE PERFORMANCE OF THE SPHS
a). Has it increased equity in the access to/utilization of
health services?
According to several studies, the SIS has improved access to health care
for the lower income quintiles, including the indigenous population (Vera
de la Torre, 2003; World Bank PID 2006; Cotlear, 2006). However, the
scheme has yet to reach the poor efficiently. By 2003, only 64% of SIS
beneficiaries came from the two poorest quintiles, and almost 50% of
SIS resources benefited the non-poor population (World Bank, 2005). A
benefit-incidence analysis carried out by the World Bank in 2004 showed
that the SIS is slightly pro-poor at the household level with a concentration coefficient of -0.08, but is slightly regressive (non-pro-poor) in terms
of geographic distribution, with a concentration coefficient of 0.04 (Cotlear, 2006). Despite these mixed figures, it is still the most equitable of
Peru’s social programs (compare its concentration coefficient of -0.08,
to that for expenditures in Ministry hospitals, 0.21) (World Bank, 2007).
And, the World Bank argues, the small grant that eliminates the economic barrier to hospital care for those in the lowest income quintiles in turn
improves the targeting of the much larger subsidies granted to hospitals
(World Bank, 2007).
Although affiliation with and resource allocation for the scheme have
favored regions with high poverty levels, the highest number of affiliations
and the greatest provision of health services so far have not been con-
126
CASE STUDIES
centrated among the poorest population. While in two Health Districts
(DISAS) affiliation and health care have mostly benefited those people
living in extreme poverty (Tumbes and Lima Sur) five DISAS (Ayacucho,
Bagua, Jaén, Loreto, and San Martín) show a regressive pattern (Vera de
la Torre, 2003).
b). Has it offset hindering social determinants?
The SEG, the SMI, and the SIS all produced a remarkable increase in
the demand for health care, especially for child and maternal health
services (Vera de la Torre, 2003). The implementation of SIS and the
corresponding availability of free prenatal and delivery care services led
to an increase in demand for maternal care. For example, institutional
births rose by 10% between 2000 and 2004. However, the SIS has been
unable to keep up with demand, and complaints of inadequate and delayed reimbursements to health care providers have arisen. As a result,
the financial problems have placed the burden of payment back on the
users (USAID, 2005).
Table 54: Performance of the SIS: social determinants
Category
Performance
yes
Offsets poverty by eliminating or reducing economic barrier
no
X
Fosters women’s social status
X
Fosters health rights through Right Charts, explicit guarantees, etc.
X
Offsets unemployment/informal labor by eliminating or reducing economic barrier
X
Offsets women’s lack of education, fostering demand for health care
X
c). Has it increased access to and coverage of appropriate
health interventions by eliminating at least one cause
of exclusion from health care?
The SIS has increased access to maternal and under-five health services.
The percentage of pregnant women living in the project implementation
area with 4 or more antenatal controls increased from 32% in 2000
to more than 57% in 2006. And the percentage of births attended by
skilled personnel also nearly doubled in the covered area, from 27.6%
to 50.9% in the same period of time (World Bank, 2007). But health care
utilization by children and teenagers 5-17 years of age has decreased
(Vera de la Torre, 2003).
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CASE STUDIES
The SIS uses public facilities to deliver health services, but it has not
improved public health infrastructure accordingly. Since it did increase
demand for health care, it has put further pressure on the public health
subsystem’s resources. And it increases fragmentation within the system
by adding yet another insurance scheme to the multiple ones already in
existence.
Although the executed expenditure for SIS is 30% higher than that of the
SEG and SMI added together, analysis of real expenses per treatment
show that SIS’s budget is far behind the real costs of the program (Vera
de la Torre, 2003). Budget deficits are not the only obstacles to improved
coverage. In a study carried out in 2005, USAID identified seven operational barriers to the provision of essential services for safe motherhood
(USAID, 2005). Besides funding shortfalls, they were:
Arbitrary and inconsistent implementation of the SIS by individual
health establishments, either because personnel at health facilities do not know SIS guidelines or because the facility’s financial
situation does not allow the provision of all the services offered
by the SIS. This leads to confusion and uncertainty for users who
expect, but not receive, free services.
Restriction of reimbursement to those services provided by physicians. Thus, the cost of care provided by midwives in cases of
low risk-pregnancies are not reimbursed and must be absorbed
by health facilities.
Professional attendance at home births and transport from
the household to a health facility are not covered by SIS. This
forces low-income rural women to choose between paying outof-pocket for transportation to a health facility or delivering at
home.
Availability of health personnel at different facilities does not
correspond to the volume of users for which each facility is responsible.
Maternal health delivery practices fail to take local culture into
consideration.
Health networks are not organized in a fashion that facilitates
the referral process.
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CASE STUDIES
Table 55: SIS. Coverage and access
SPHS
Category
yes
Increases coverage (rise in number of people covered as a % of eligible population)
no
X
Establishes a single guaranteed portfolio of entitlements with the same quality, content, and
delivery conditions for all socioeconomic groups so as to avoid segmentation
X
Increases coordination/integration within the system so as to avoid fragmentation
X
Improves resource allocation and organization of health interventions by increasing number
and capabilities of human resources in previously underserved areas
X
Improves resource allocation and organization of health interventions by increasing the
amount of public spending allocated to the scheme
X
Public spending allocated to the scheme is progressive
X
Improves geographical distribution of the service delivery network and health infrastructure
by increasing number/amount of health facilities, equipment, medical devices, and drugs in
previously underserved areas
X
Increases information system’s coverage
X
Increases access (number of people who access health goods or services provided by the
scheme)
X
Eliminates/reduces geographic barrier
X
Eliminates/reduces economic barrier
X
Eliminates/reduces gender barrier
X
Eliminates/reduces employment status barrier
X
Improves access to drinkable water, sewerage, roads, and/or transportation
X
Improves refuse collection
X
d). Have health outcomes improved?
Health outcomes have certainly improved in Peru since the implementation of SIS, but there is little evidence to link SIS to the improvements in
health. The World Bank reports that the Infant Mortality Rate fell from
48 to 28.3 in the project area during the implementation period (20002006), a drop of 41%. But Peru’s overall IMR actually fell by 45%, implying that the observed improvements were not necessarily due to project
implementation (World Bank, 2007). It is difficult to state, however, how
much of this decline was due to the SIS. Access to diarrhea treatment increased by 16% in the same period, which does seem attributable to SIS.
Births attended by skilled personnel through SIS increased by 9% (from
65.4% to 71.4%) between 2002 and 2004 (Ministry of Health, 2006).
The fact that perinatal mortality has increased relative to other causes of
infant mortality inspires some concern about the quality and coverage of
perinatal care.
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CASE STUDIES
Graph N. 7
Infant Mortality Rate in Peru,
1996-2006
45
40
35
30
25
1996
1998
2000
2002
2004
2006
SOURCE: United States Census Bureau, International Database, 2007.
Table 56. Performance of SIS
130
Goal
Performance
Increase equity in the access to and/or utilization
of health services
Mixed results so far. It has increased equity at the individual (household) level; shows a regressive pattern in the
geographic distribution of health services utilization
Offset social determinants that hinder demand
for health care and/or hamper health status
It has increased the demand for health care. It helps
offset poverty
Increase access to and coverage of appropriate
health interventions by reducing or eliminating at
least one cause of exclusion in health
It has increased access by reducing the economic barrier.
Coverage has not been strengthened accordingly
RESULTS
6
6.1
RESULTS
Overview of the SPHS analyzed
The seven SPHS analyzed are classified according to the conceptual
framework as shown in table 57.
Table 57: Social Protection in Health Schemes (SPHS) analyzed
Name
Type
Country
Year of
creation
Seguro Universal Materno- Infantil
(SUMI)
Free maternal and child care
Bolivia
1996
Programa Saúde da Família (PSF)
Primary health care provision
Brazil
1994
Mother and Child Health Protection
Plans (MCHSHPP)
- Public Health Insurance
- Primary health care provision
- Conditioned in-kind transfer
Chile
1979
1995
1952
Ley de Maternidad Gratuita y Atención
a la Infancia (LMGYAI)
Free maternal and child care
Bono Materno-Infantil (BMI)
Conditioned cash transfer
OPORTUNIDADES
Conditioned cash transfer
Seguro Integral de Salud (SIS)
Free maternal and child care
Primary health care provision
Ecuador
Honduras
Mexico
1997
Peru
2001
1994
1990
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RESULTS
6.2
Analysis of the strengths and weaknesses
of the SPHS
6.2.1
INCREASE EQUITY IN THE ACCESS TO AND/OR
UTILIZATION OF HEALTH SERVICES
Four out of the seven schemes under analysis - Bolivia’s SUMI, Brazil’s
PSF, Chile’s MCHSHPP, and Mexico’s OPORTUNIDADES - have increased equity in the access to and/or utilization of health services. Two
programs - the LMGYAI and SIS - show mixed results and in some cases
increase inequity in the access to or utilization of health services. Not
enough information on the BMI has been gathered to assess whether or
not it has increased equity, but studies of its previous incarnation found
that its effect was limited due to poor targeting and low coverage.
The source of equity problems in the operation of the LMGYAI and SIS is a
combination of poor targeting and low utilization on the part of the target
population. Often this latter factor is the result of geographical or cultural
barriers – health services are not available in the area, or they are offered
in a different language or with a different set of cultural assumptions from
those of the local inhabitants. In the case of LMGYAI, outreach efforts
have been too minimal to attract new users to the program.
But even those programs with a generally progressive impact face problems. In Bolivia, the SUMI must focus on dealing with cultural and geographic barriers to continue to improve equity in the access to and utilization of health services. Vast health inequalities between rural and urban
areas persist, a situation that may require a more active focus on poor
mothers and children than SUMI can provide.
The mechanism through which OPORTUNIDADES targets eligible families - a two stage process, involving the selection of the localities first and
then the selection of beneficiary families within the selected localities - has
been highlighted as the main factor in the program’s progressive spending. However, the proportion of beneficiaries from the top two income
quintiles has been rising. Consequently, it remains to be seen whether the
expanded program can replicate the highly progressive spending of its
early years. Unless targeting efforts improve, middle-class families may
receive cash payments meant to encourage them to demand services
they would already have used.
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RESULTS
The fact that Chile and Brazil’s SPHS are universal and horizontally delivered may explain the increased equity in access to and utilization of
health services. In both cases the better-off may opt out of the schemes,
but the poor stay. Brazil’s PSF is an effective combination of horizontal
and targeted delivery with poorer areas the first to receive health teams,
while the MCHSHPP exhibits the high coverage of a mature, well-funded
program. The national scope of the programs and the fact that the SPHS
are implemented all over the country account for the reduction in geographic barriers in Chile and Brazil, although geographic accessibility
continues to be a challenge in both countries, especially - given its size
- in Brazil.
6.2.2
OVERCOME SOCIAL DETERMINANTS THAT
NEGATIVELY IMPINGE UPON HEALTH STATUS AND/
OR PREVENT THE DEMAND FOR HEALTH CARE
All of the schemes under consideration helped to offset at least one of
the negative social determinants of health, most frequently poverty, but
only four of the analyzed schemes - Bolivia’s SUMI, Brazil’s PSF, Chile’s
MCHSHPP, and Mexico’s OPORTUNIDADES - had a clear and unambiguous effect. All of them have helped to offset poverty among the covered
population, increasing the demand for health care.
In the case of OPORTUNIDADES - a conditioned cash transfer program
- the amount of the transfer, which represents a 25% increase in family
income, is successfully helping to offset poverty among beneficiary families. The program’s high coverage, which allows it to effectively reach
those in need, is also an important component of its success. This is in
contrast to the mixed performance of the BMI, whose much smaller transfer represents only a small portion of income (about 10%, according to
some estimates). It remains to be seen whether the BMI achieves better
results in terms of overcoming the health effects of poverty in the coming
years, as transfers rise significantly.
Another conditioned transfer program - Chile’s PNAC - has successfully
changed patterns of demand for health care over the years by conditioning the delivery of milk and cereals to health check ups for pregnant
women and children. It has also improved the nutritional status of mothers and children. Continuity through different governments, a focus on
promoting health-seeking behavior, close monitoring of results, and a
sense of national ownership (the program is delivered in public as well as
in private facilities all over the country) seem to be key to PNAC’s success.
The in-kind transfers of PNAC also make it easier that resources are used
specifically to benefit mothers and young children, unlike in OPORTUNIDADES and the BMI, where cash transfers may be used to meet the needs
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RESULTS
of other family members. In Chile, issues of fairness within the family are
at least partly addressed by the Programa de Alimentación Escolar, which
complements the PNAC providing benefits to school-age children.
The Chilean Public Health Insurance, FONASA, has increased awareness of the right to heath among Chilean citizens. Years of campaigns
promoting the Patient’s Chart and making public the contents of the
public insurance health plan have brought about changes in the pattern
of demand for health care, making quality and the content of health
packages central issues and therefore improving quality of delivery in the
public facilities and prompting the health insurance companies, ISAPRES,
to adopt FONASA’s health plan as the benchmark for their own diverse
health packages. It would be somewhat misleading to measure the shortor medium-term results of the other SPHS analyzed in this paper against
Chile’s outcomes after for intance, fifty years of implementation of the
PNAC, but some SPHS show promising signs of increased beneficiaries of
its empowerment. The LMGYAI, which offers a specific set of benefits encoded in the law, is very clear on patients’ rights, although it is difficult to
assess to what extent Ecuadorians are aware of them. Brazil offers a limited statement of Patient’s Rights in their National Sexual and Reproductive Rights Policy, which guarantees certain reproductive health rights.
Mexico’s OPORTUNIDADES program has achieved the most noteworthy success in the area of women’s empowerment. The program’s specific focus on gender issues (turning benefits over to the female head of
household over the male and increasing benefits for female students at
the secondary level and beyond) has resulted in increased empowerment
of women. In the long term, the program will hopefully increase the average educational level of female children of beneficiaries (since parents
of female students receive higher transfers), helping to offset a major
social determinant of health. Ecuador’s LMGYAI, passed with the specific
support of women’s groups, helps to empower women by making their
health a national priority.
6.2.3
INCREASE ACCESS TO AND COVERAGE OF TECHNI
CALLY APPROPRIATE HEALTH INTERVENTIONS BY
ELIMINATING ONE OR MORE CAUSES OF EXCLU
SION IN HEALTH
We found that all of the seven analyzed schemes have contributed to
increasing access to technically appropriate health interventions by reducing at least one cause of exclusion in health. All of them remove
economic barriers by providing financial protection. All of them achieve
some degree of solidarity in financing by funding the interventions through
general taxes, along with other sources. But while all of the programs un-
134
RESULTS
der consideration have increased access to health interventions, in many
cases it remains unclear whether they have increased access to quality
care.
Both the Chilean Plan de Salud Familiar and the Brazilian Programa
Saúde da Família have contributed to overcoming geographic isolation
as well as geographically determined income disparities, i.e. the effect
of living in a poor locality. The national scope of both programs, the
important investment made in the supply-side – usually in the form of
public primary health care facilities - as well as the progressiveness of
the payment mechanism (in the case of Chile), seem to account for this
achievement. The amount of investment, the degree of coverage, and
continuity over time appear to be the crucial factors in the ability of these
SPHS to deal with negative social determinants. Despite these successes,
the Brazilian PSF struggles with quality of care issues.
The reduction of geographical barriers to access achieved in Chile and
Brazil is not the norm. In Peru, for example, under-funding, poor coordination among health centers, and lack of transportation has hindered
access to health care in poor and rural areas. Poor distribution of health
care facilities in Bolivia and Ecuador, where services tend to be concentrated in richer and/or urban areas, means that the geographical barrier
to health remains an impediment for many women, even when the economic barrier is removed by the SPHS.
OPORTUNIDADES has significantly increased utilization of health services, but many users report dissatisfaction with the quality and accessibility
of services, as is seen in Ochoa and Garcia’s report from Chiapas. In the
case of Bolivia’s SUMI, low quality of care, and low cultural adaptation
of the provision of servicies delivery seem to be the main challenges. And
although the BMI has significantly increased demand for health interventions in Honduras, there is no evidence that the increased utilization of
health care has led to improved health outcomes, which implies either
that the care is of poor quality or that other social determinants of health
must still be overcome.
Only in two cases - those of Chile’s MCHSHPP and Bolivia’s SUMI have schemes achieved more than 60% coverage of the eligible population. This high coverage accounts to a great extent for the success of
the MCHSHPP, and is at least partly the result of long-term commitment
to the program on the part of the Chilean government. Although, as
mentioned above, continuity is crucial to achieving such high coverage,
institutional capacity and the degree of decentralization of the program’s
management seem to play an important role as well, as seen in the outcomes of Bolivia’s SUMI and Ecuador’s LMGYAI.
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RESULTS
Table 58. Coverage
Health
protection
scheme
Scope
Years of
implementation
Reported
coverage:
% of
eligible or
targeted
population
Reported
coverage:
number
of people
covered
Date of
report
Source
SUMI
national
9 years
74%
1,600,000
2004
Ministry of
Health
PSF
national
11 years
42.7%
74,298,000
2005
Ministry of
Health
13 years PSF
90% (PSF)
13,500,000
2005
28 years
FONASA
68.3%
(FONASA)
11,000,000
2007
53 years PNAC
81.2%(PNAC)
905,903
2004
MCHSHPP
national
Ministry of
Health
LMGYAI
national
9 years
30%
3,867,000
2004
Vos et al.
BMI
sub-national
15 years
51.8%
105,614
2004
Government
of Honduras
OPORTUNIDADES
national
10 years
40%
25,000,000
2007
Sedesol
SIS
national
5 years
39.6%
11,026,607
2006
Ministry of
Health
Table 59. Compliance with performance parameters
Health protection
scheme
Increases equity
in access/utilization
yes
no
Offsets hindering social
determinants
yes
no
Increases access / Increases
coverage
yes
no
yes
SUMI
X
X
X
X
PSF
X
X
X
X
MCHSHPP
X
LMGYAI
X
BMI
X
OPORTUNIDADES
SIS
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Not enough data has yet been collected regarding the financial
sustainability of the SPHS. However, four out of the seven schemes SUMI, LMGYAI, BMI, and SIS - reportedly face financial shortages that
may threaten their sustainability.
136
no
DISCUSSION AND LESSONS LEARNED
7
DISCUSSION AND LESSONS
LEARNED
Several questions arise from an analysis of the outcomes of the different
SPHS, as well as certain issues that must be discussed.
a).
Is it useful to analyze the SPHS with the
parameters established in this paper?
The parameters established in this paper (increase equity in access to
and utilization of health services; help offset negative social determinants
that deteriorate health status or hamper the demand for health care; and
increase the access to and coverage of appropriate health interventions)
are all in line with the schemes’ declared objective of helping to achieve
universal access to appropriate health interventions and increase equity
in health. These parameters should be used on a regular basis to monitor
the performance of the SPHS.
b).
The importance of primary health care
There is considerable information showing that Primary Health Carebased Health systems23 “are more likely to have better and more equitable health outcomes, be more efficient, have lower health care costs, and
23
We adopt here the definition stated in the document “Renewing Primary health care in the Americas. A position paper of the
PAHO/WHO” published in Washington DC, 2007. Therefore, we define a PHC-based health system as one that makes the right
to the highest attainable level of health its main goal while maximizing equity and solidarity through an overarching approach
to its organization and operation.
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DISCUSSION AND LESSONS LEARNED
achieve highER user satisfaction than those health systems with a weak
PHC orientation” (PAHO/WHO, 2007). In the Americas, the experience
of Costa Rica illustrates that a system with a strong emphasis on PHC
can improve health outcomes. After five years of implementation of a
PHC-oriented health reform, child mortality in Costa Rica was reduced by
13%, even after controlling for other health determinants (PAHO/WHO,
2007).
The main attributes of a PHC-based system are: accessibility, continuity,
comprehensiveness and coordination. This means that the primary health
care team provides a continuum of care that combines preventative, palliative and curative care for a variety of health problems for a wide range
of patients, irrespective of social class and cultural background. Studies in Mexico, Bolivia and India show that PHC programs that focus on
improving the health of socially deprived populations in less developed
countries or territories, succeeded in narrowing the gaps in health between these groups and more socially advantaged populations, thus reducing inequity (De Maeseneer et al., 2007).
By focusing on the needs of the population within a specific territory, PHC
also has the potential for empowering the communities reached by it.
PHC teams identify the community’s health problems, implement specific
interventions to address priority health issues and monitor their impact
over time on the health of the population. PHC also favors intersectoral
collaboration as a mechanism to better address the community’s needs.
In summary, the PHC approach, operating in a network with other sectors can promote health equity through increased social cohesion and
empowerment (De Maeseneer et al., 2007).
The Brazilian and Chilean cases show that allocating resources to primary health care and bringing health services to where they are most
needed significantly improves equity in access to and utilization of health
services, regardless of the amount of public health expenditure. This lesson may be useful in continuing to allocate resources to primary health
care through LMGYAI in Ecuador.
138
DISCUSSION AND LESSONS LEARNED
c).
Sustained political and financial commitment, no matter the political contingency
The experiences of the SPHS under review show that sustainability and
long-term political commitment are two of the most important external
factors that determine a program’s success. More than a temporary or
one-time agreement between parties, political support for a program
must be based on long-term societal commitment. Peru’s current SIS and
Ecuador’s LMGYAI may benefit from social and policy dialogue to bring
about wider consensus and support for those countries’ SPHS.
In addition, significant investment must be made in order to achieve an
adequate degree of protection in health. A large factor of success in the
case of Chile’s programs was the continued support for maternal and
child health programs over time. Even though there were drastic cuts on
public expenditure on health during the Pinochet’s government, the fact
that the remaining resources were channeled into child and maternal
care maintained the advances in this field. Again, although macroeconomic constraints may exist, the analysis shows that only those countries
that invest in health, education, and other social services with an eye for
the long term are likely to reach the social development that is necessary
for economic development.
Too little spending can be almost as bad as none at all. A comparison
of the results of the BMI in Honduras and OPORTUNIDADES in Mexico
illustrates the importance of adequate allocation of resources for SPHS.
The small transfers provided by the BMI have mostly failed to lift families
out of poverty, simply because they represent too small a percentage of
average family income. In Mexico, a greater financial commitment has
resulted in larger transfers that have had a real impact in family income.
Honduras, recognizing this problem, has committed to increasing transfers significantly, but it remains to be seen whether this increase in funding will be sustained by successive governments. And as the experiences
of the SIS and the LMGYAI show, political and financial commitment to
eliminate the economic barrier to health care may not achieve the expected results without a corresponding effort to improve the quality and
availability of services.
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DISCUSSION AND LESSONS LEARNED
In the context of the urgency created by widespread poverty and high
maternal and infant mortality rates, interventions that help achieve quick
gains in improving health outcomes for mother and child populations
may be confused with sustainable solutions. However, in a setting characterized by low levels of institutional capacity and a lack of sustainable
financing, additional progress in achieving health outcomes that extend
beyond these initial gains may prove to be increasingly difficult. The Chilean case shows that further improvement in the health status of mothers
and children strongly depends on strengthening institutional capacity as
well as on providing equitable access to jobs and basic services such as
roads, transportation, electricity, recreation areas, refusal recollection,
water, and sanitation.
d).
Stigma vs. Social cohesion
Among other definitions, social cohesion has been defined as “the ongoing process of developing a community of shared values, shared challenges and equal opportunity within a given country, based on a sense of
trust, hope and reciprocity among all citizens.”24 Stigma, discrimination,
stark differences in income and access to good and services, and social
exclusion have been identified as leading to the lack of social cohesion
(WHO, 2003). On the other hand, social health protection and long-term
care is an essential issue in the context of social cohesion. According to
GTZ-ILO-WHO Consortium (2007), social protection in health bears a
potential to foster economic growth via three channels, one of them being its contribution to social cohesion and social peace, which are prerequisites for sustainable economic growth. Social cohesion implies the
existence of some sort of joint endeavour. It involves shared values and
rules which give the members of society a sense that they all belong to
the same social body. The examples of Chile’s PNAC and FONASA and
Brazil’s PSF indicate that shared ownership and awareness regarding the
right to health are powerful tools to increase citizenship, create a sense of
social responsibility, and contribute to increase social cohesion.
24.
140
Social Cohesion Network, Policy Research Initiative, available at
http://www.schoolnet.ca/pri-prp/networks/cohsoc/socialco-e.htm
DISCUSSION AND LESSONS LEARNED
Stigma is a problem policymakers have to deal with regarding the implementation of social protection schemes, especially when they seek to
reach a diverse population in terms of social status, income, and ethnic
background. The analyses of Bolivia’s SUMI, Ecuador’s LMGYAI, and
Peru’s SIS suggest that further improvements in coverage might require
training health workers and administrators to fight stigma related to ethnic background in the point of service.
e).
There must be a balance between fostering
demand for health care, increasing access
to health services, and improving health
infrastructure
The mixed successes of the SPHS reviewed here show that simply eliminating one or more access barriers to health care is not enough to guarantee health for all. Effective social protection in health is the result of a
combination of actions in multiple fronts. The analyses of Bolivia’s SUMI,
Ecuador’s LMGYAI, and Peru’s SIS indicate that efforts to increase access
to already available services and to foster the demand for health care without strengthening health system infrastructure correspondingly - can
place the health care network under strain and may affect quality and
availability of health care both for the people who are new to the system
and for those already covered before the scheme was put in place. In
order to avoid this, the health care delivery network must be strengthened
as programs are expanded.
The early years of implementation of the SIS in Peru are instructive. The
program successfully increased demand for health care without having
adequately prepared health centers and managerial support for the surge
in demand. As a result, slow or non-existent payments to doctors made
them wary of accepting beneficiaries of the SIS for treatment. And underequipped health centers often did not have the resources to provide the
guaranteed portfolio of services to all beneficiaries who requested it.
The case of Ecuador is also illustrative. The passing of the LMGYAI technically removed the economic barrier to health care for the mother and
child population. But the increased demand for health care that followed
put a strain on the resources of the health delivery network, resulting in
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DISCUSSION AND LESSONS LEARNED
limitations on access due to low availability of some goods and services
such as medicines. Coverage remains low in rural areas and among indigenous communities. Improvement of the health infrastructure to handle new demand and to allow for the expansion of services throughout
the country will help the LMGYAI to better achieve its goals.
Infrastructure issues may also affect the sustainability of the BMI in Honduras. The mixed success of the BMI has at least spared the country’s
already over-burdened health system. But if coverage increases, infrastructure will have to be improved accordingly. Even those countries with
more successful programs, such as Mexico and Brazil, have felt the strain
placed on health infrastructure by an increase in demand. In Brazil, poorquality care is far more common among users of PSF than of private primary care.25 In Mexico, the majority of infant deaths take place in hospitals. Reducing infant mortality will thus require attention to infrastructure,
human resources, and quality of care (Aguilera, 2007).
f).
Overcoming the economic barrier is important but not sufficient
In ethnically diverse countries, and/or those with geographically isolated
settlements, removing the economic barrier may not be enough to eliminate exclusion and grant access to health care, as shown by Bolivia’s
SUMI, Honduras’s BMI and Peru’s SIS. Further efforts must be made to
reduce or eliminate cultural and geographic barriers. And more attention must be paid to delivery networks problems that result in denial of
services (see section e above).
In Bolivia, the provision of free care for the mother and child population
has not been enough to overcome existing equity gaps between income
quintiles and urban and rural populations. Although the implementation
of the SUMI has increased utilization across the board, it has not corrected preexisting inequities, and the average affiliate is still a relatively welleducated urban dweller. This may be due in part to geographic barriers:
many of those in rural areas can not reach a health center (the Bolivian
Ministry of Public Health is attempting to combat isolation from health
25. Barros, Aluísio J.D., Cesar G. Victora, Juraci Cesar, Nelson Arns Neumann, and Andréa D. Bertoldo “Brazil: Are health and
nutrition programs reaching the neediest?” in Reaching the Poor with Health, Nutrition and Population Services. The World
Bank, Washington D.C., 2005
142
DISCUSSION AND LESSONS LEARNED
services by the addition of mobile health brigades under the Extensa program). And cultural barriers to health can still prevent utilization of care.
In Honduras, utilization of services has increased markedly among beneficiaries of the BMI, but there is no evidence that health outcomes have
correspondingly improved. This is a reminder that ensuring access to
health care is not the same thing as ensuring access to health. Low quality of care and negative social determinants can thwart even the highest
coverage of care. The case of Honduras may indicate that overcoming
the economic barrier to care is not enough to offset the negative impact
of poverty on health.
Countries that have successfully eliminated geographic barriers, such as
Chile, Mexico and Brazil, have usually done so through the use of either
targeted programs (PNAC, OPORTUNIDADES) or universal programs
whose implementation is focused on targeted areas where access to
health care is difficult (Brazil’s Programa Saúde da Família, Chile’s Programa de Salud Familiar). However, even a successful program like both
PSFs may find it difficult to cover large areas of sparsely populated land.
Brazil’s isolated Amazon Region has far lower rates of coverage than the
rest of the country, often below 25%; and some areas have no coverage
at all (Sampaio, 2007).
g).
The challenge of migration
Migration is a widespread phenomenon in the LAC countries, within
countries as well as between them. In some cases, migration has been
shown to have a positive effect on certain health indicators, including
maternal and infant mortality (Development Research Centre, 2005).
This may be because migrants usually travel from rural to urban areas
where health care is more widely available and more institutionalized.
But the health status of rural-urban migrants is usually poorer than that
of other urban residents, and migrants, especially those participating in
illegal or forced migrations, face many dangers while in transit (Development Research Centre, 2005).
SPHS that are targeted to certain geographical areas, as well as universal schemes that focus their initial implementation on certain areas,
present the problem of covering migrants both to and from the target
area. This is a problem that territorially-based schemes, such as OPOR-
143
DISCUSSION AND LESSONS LEARNED
TUNIDADES, may have to face. Cash-transfer schemes, which condition
benefits on the fulfillment of certain co-responsibilities, are particularly
prone to letting temporary or seasonal migrants slip between the cracks.
Fulfillment of co-responsibilities in schemes like OPORTUNIDADES and
the BMI require registration at a local health center, requiring long-term
residence in one place. Such programs must develop the informationsharing capacity to allow their beneficiaries to fulfill their co-responsibilities and receive care and the cash transfers in health centers all over the
country. Furthermore, successful geographically targeted schemes may
attract more migrants to their areas of operation, putting undue strain
on local health infrastructure. Only truly universal schemes that eliminate
both the economic and the geographic barrier are likely to be able to
cover migrants at all points of their life.
Rural to urban migration, by concentrating population in urban areas,
is acting to counterbalance the concentration of heath services in urban areas that is seen in so many LAC countries. The challenge for LAC
countries is to fully incorporate both rural populations and rural-urban
migrants into the network of SPHS.
Using citizenship as a condition for access poses the same challenge for
national schemes that must confront immigration from other - usually
poorer - countries. But while citizenship conditions make it more difficult
for immigrants to enroll in certain SPHS, they are at equal, if not greater,
risk for poor health. Many studies have shown that migrants, especially
illegal ones, are far more vulnerable than legal inhabitants of a country
and that they often lack any form of social protection (Sabates-Wheeler,
2003). Inter-country or inter-regional agreements should be considered
as avenues to overcoming these restrictions. The development of portable social protection across national borders may be key to achieving
true universal social protection in health.
144
DISCUSSION AND LESSONS LEARNED
h).
The advantages and limitations of targeted
programs
Targeting is often a less than ideal approach to providing protection:
it is difficult to avoid wrongful exclusion and inclusion, it is expensive
and administratively difficult to do well, and it reduces social solidarity
(Shepherd, Marcus, Barrientos 2004). However, targeting has certain advantages in reaching vulnerable or excluded groups when universal and
equitable access to health care is not within reach. Targeted in-kind or
cash-transfer programs have been shown to be successful in increasing
demand for health care when they are conditioned to health seekingbehavior and used as incentives to health services utilization, as with the
PNAC in Chile and Mexico’s OPORTUNIDADES. As learned from these
experiences, conditioned programs achieve better outcomes when they
are directed to families instead of individuals and when the mother is the
recipient of the monetary or in-kind benefit. The case of OPORTUNIDADES also shows that giving control of monetary benefits to the mother
improves the status of women within the family.
However, issuing age-targeted conditioned-transfer schemes in a scenario of widespread poverty and without further support to the beneficiary families brings up the issue of equity inside the household and how
resources are distributed within the family. What happens with the food
or the money designated for children under five and pregnant mothers
once it reaches the household and there are several family members to
feed and various family needs to meet is impossible to control. The fact
that Honduras’s BMI has achieved little improvement in poor children’s
nutritional status forces us to question how the money was used.
And targeting the maternal and child population, using age or pregnancy
as a main criteria, brings up the question of equity of access to health for
the rest of women of reproductive age and for older children. Although
targeted schemes may provide preventive services that could benefit the
covered children once they grow up, this may not be enough to satisfy
their health needs, especially when there are no other services available
to them on a regular basis. It is important to explore whether the gains
made in avoiding mortality in the under-five population still translate into
a better quality of life and longer life expectancy for children who go
without health care between the ages of 6 and 15 (when they may again
be targeted by reproductive health programs).
145
DISCUSSION AND LESSONS LEARNED
In the case of women’s health care, targeting only those who are pregnant begs the question about whether this may be an incentive for poor
women to become pregnant in order to access health care and related
benefits. While fertility rates decreased in Bolivia between 1989 and 2000
under the SBS, which included women of childbearing age, it would be
useful to monitor the fertility rate trend among the poor starting in 2003,
when SUMI began to restrict benefits to pregnant women.
PNAC is a successful example of using age-targeted mechanisms to
reach universal coverage while still striving for vertical and horizontal equity. PNAC is aimed at children under six years old and is continued when
this population group ages out (turns six) by the School Food Program
(Programa de Alimentación Escolar) which is administered in schools.
Insurance schemes that target the poor must face the challenge of a risk
pool that increases in inverse proportion to the beneficiaries’ ability to
contribute. The experience of FONASA and SIS show that, in order to be
sustainable, the insurance scheme should look for diversity in terms of
age, social status, income and economic activity of the people included
in the pool.
Whatever the selecting criteria, targeting specific population groups requires making investments in targeting technology and continued monitoring, lest the actual beneficiaries of the program end up being the
upper income quintiles, as has happened in the case of Peru’s SIS. When
targeting technology is not fully developed, the best targeting is the lightest – targeting can be carried out where there are simple categories
which make sense (age, location, widely recognized degree of exclusion), within which provision ideally should be universal. As administrative capacity evolves, more sophisticated approaches to targeting can be
undertaken.
Disease-based targeting is one form of targeting that should be avoided
at all costs, due to the disadvantages it has shown in the field. From an
operational standpoint, the main constrain of disease-based programs
is that funds are directed through narrow channels to a particular program/disease, meaning that the government has a big amount of money
to support certain specific activities related to that program -for example,
ARV-distribution to mothers and children- but cannot use that money to
146
DISCUSSION AND LESSONS LEARNED
support the provision of basic health care services such as obstetric care
or well child check ups. The shortcomings of disease-based programs
running outside health systems with their own budget, management and
personnel have been widely acknowledged: low or no community participation, donor-driven approach that has weakened the National Health
Authority, lack of coordination of donors activities, little impact on equity,
drain of human resources from health systems to the programs (Garrett,
2007; Jack, 2007; Lewis, 2005). This form of targeting should be carefully avoided when creating social protection in health schemes.
i). The necessary learning curve
The differing results of the LMGYAI and SIS show that a necessary learning
process must occur for the scheme to improve its results. Both schemes
show improvements over time, both in their ability to increase access to
health services and to improve equity in access to and/or utilization of
health services. The learning curve is most clear in the case of the SIS,
which has performed remarkably better than its predecessors, the SMI
and SEG.
In summary, as other studies suggest, sustaining affordable long-term
improvements in safe motherhood and child health depends on improving the functioning of health systems as a whole. This in turn means that
health sector reforms have large implications for achieving these goals.
Improvements resulting from vertical and targeted approaches may raise
expectations while undermining the overall system. Although important
achievements can be made in the short run through the implementation
of targeted programs, the development of the whole health system and of
sound intersectoral policies is the key to achieving sustainable development in the long run.
A sustained political will and commitment to improving social outcomes
is clearly a crucial factor in successfully extending social protection in
health to all mothers and children. Continuity in decisions, investments
and outcomes seems to be key to success, regardless of the political
contingency. There is no overnight solution.
147
DISCUSSION AND LESSONS LEARNED
Expanding financial coverage by merging various partial schemes and
extending entitlements to the whole population obviously requires sufficiently increasing public funding to ensure an adequate supply of services, with a benefits package that covers a wide range of interventions,
including those required to improve maternal, newborn, and child health.
The challenge is to capture the different sources of funding so as to scale
up both access and financial protection in a stable and predictable way.
In most countries, financial sustainability will only be achieved in the short
and middle term by looking at all sources of funding: external and domestic, public and private.
As Dr. Abraham Horwitz stated long time ago, there is a “golden cluster” of actions that lead to success in protecting the health of mothers,
newborns, and children: these actions include ensuring the provision of
health services and equitable access to those services, making policy
decisions based on sound information systems, and interventions in education, water and sanitation, family planning, and nutrition.
The technology and knowledge to extend social protection in health to
all mothers and children is available. The agreement and alignment of
all of the players involved both in the national and in the international
community, is required to achieve this goal.
148
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